FOR MEN over 50, the PSA test for possible prostate cancer has been a regular part of an annual physical. Now a government panel says it’s time to end that practice. But while the test can lead to overtreatment of some prostate patients - and all patients and doctors could use some reassurance that, in a variety of circumstances, holding off on tests and treatments may be the wisest course - this recommendation is too sweeping.
The PSA test has been a staple of male medical care for a decade and a half. A low level of prostate-specific antigen has imparted a sense of assurance, while an elevated rate has led to worries about possible cancer. A bad PSA test is often the first step toward a biopsy and, if that comes back positive, treatment for prostate cancer.
Now the US Preventive Services Task Force, a creation of the Department of Health and Human Services, is recommending that most middle-aged men forgo the test.
The panel’s reasons are several. For one, the PSA test has a high rate of false positives, particularly in the lower warning range. That’s true because conditions other than cancer can lead to elevated PSA levels.
Second, though prostate cancer is relatively common in men, in most cases, it is very slow-growing. Thus, many men die with prostate cancer, but not from it. Treating the cancer in those cases doesn’t make sense, the panel says, particularly since the treatment can leave patients at least temporarily impotent or incontinent. Taken as a whole, then, the task force concludes, the test leads to more harm than it prevents.
That recommendation has triggered considerable controversy. Other medical experts, urologists prominent among them, insist that the PSA test is an important diagnostic tool. And though it’s true that most prostate cancers won’t be lethal, the fact remains that some 30,000 American men die from prostate cancer each year.
Further, though the panel necessarily assesses effects of PSA screening on patients in the aggregate, individual patients aren’t just data points. Many prefer to know as much as possible about threats to their health. There’s something troubling about the suggestion that ignorance about a possible problem is, for all men, preferable to awareness.
A better course would be for physicians to talk with their patients about both the uncertainties inherent in the PSA test and the relative innocuousness of most prostate cancers. Some patients may find the panel’s recommendation reason enough to forgo the test. Others patients might prefer to have it done, but to monitor their PSA levels rather than seek immediate treatment when the results are borderline.
Insurance companies often use the panel’s recommendations as their criterion for whether to cover a test. But until there’s a better test to detect prostate cancer or a broader consensus about skipping this one, insurers should continue to cover it.