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Men are left to wonder as PSA test is disputed

By Deborah Kotz and Carolyn Y. Johnson
Globe Staff / October 8, 2011

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New recommendations against using the PSA test to screen healthy men for prostate cancer could lead to a dramatic drop in use of the test now routinely given to about 75 percent of men over 50, but only if doctors follow through and change what they say to patients.

An independent panel of specialists concluded in draft recommendations posted online that the harms from screening outweigh the benefits for healthy men, and some Boston primary care physicians interviewed yesterday said they routinely listen to the US Preventive Services Task Force’s advice and will urge patients not to have the blood test to measure prostate-specific antigen, or PSA.

But leading area cancer experts said not so fast. They point to recent research, which they say showed a drop in prostate cancer deaths among some groups of men who were regularly screened.

The disagreement makes clear that ultimately men have to make their own choice.

“I’m very confident that different men will make different decisions; I’m reluctant to say one size fits all here,’’ said Dr. Michael Barry, medical director of the John D. Stoeckle Center for Primary Care Innovation at Massachusetts General Hospital.

Barry said he discusses the pros and cons of PSA testing with his male patients. “What I think is very important is that men aren’t oversold on the benefits of this test,’’ he said.

The recommendations are based on a scientific review of more than 30 studies showing that screening for prostate-specific antigen results in little or no reduction in cancer deaths and may result in harm such as incontinence and impotence from overtreatment of slow-growing cancers that never would have become life threatening.

The influential task force, which evaluates a broad range of preventive services and issues periodic statements on their merits, downgraded PSA screening from a grade of I for inconclusive to D, for no benefit for men under age 75. The guidelines could be tweaked after a one-month public comment period.

Primary care physicians are the ones who typically offer PSA testing to patients, and at Boston Medical Center, Dr. Jonathan Berz said he will probably change the advice he gives patients, no longer simply laying out the risks and benefits. “Now I may feel justified in saying it’s not a good test for them,’’ he said, adding that he is going to direct the residents he trains to do the same.

Elevated readings on the test may signal the presence of cancer, but there is no agreement on what level indicates a tumor. Studies show 13 percent of men who have regular PSA screenings wind up with at least one false PSA finding for every four screenings they have, while nearly 6 percent undergo a biopsy for this false reading. These biopsies can lead to infections, bleeding, and urinary problems.

“Once you send off the PSA tests, it’s potentially sending patients down a road that’s hard to turn back from,’’ Berz said.

But leading medical oncologists called the new recommendations misguided, similar to the reaction from breast cancer specialists to the task force’s 2009 statement questioning the need for routine mammography for women under 50.

“I don’t believe the panel is correct in its conclusions,’’ said Dr. Philip Kantoff, director of the Lank Center for Genitourinary Oncology at Dana-Farber Cancer Institute in Boston. “Not everyone needs screening, but eliminating it altogether could eliminate the possibility of saving tens of thousands of lives.’’

He cited a large European trial published in 2009. While it found no overall mortality benefit to PSA screening, a subgroup of men ages 55 to 69 randomly assigned to have PSA screening had a 20 percent reduced risk of dying from prostate cancer during nine years, compared with men who had no screening.

Kantoff and other oncologists believe that avoidable harm to patients can be reduced by treating only men with aggressive cancers and monitoring those with slow-growing ones.

Dr. Anthony D’Amico, professor of radiation oncology at Brigham and Women’s Hospital, said two studies published within the last year found that screening and treatment could significantly reduce deaths from cancer in a subset of men.

“If you look at the follow-up data, in fact, it suggests just the opposite of what the guideline is suggesting,’’ D’Amico said. “I think the right answer is that healthy men appear to benefit.’’

One patient who believes he did is Adam May of Needham. “I probably wouldn’t be alive today if it wasn’t for that test,’’ said the 49-year-old sales representative, who was diagnosed with an aggressive form of prostate cancer four years ago. “When I was 45, my PSA jumped from two years previously; I had a biopsy done and had a malignant tumor.’’ He said he is cancer-free after radiation and hormone treatments.

Members of the panel that issued the recommendations defended them yesterday.

“The common perception is that PSA early detection prolongs lives, but that’s not supported by the scientific evidence,’’ said Dr. Mike LeFevre, co-vice chairman of the panel.

It relied in part on a 2009 clinical trial, sponsored by the National Cancer Institute, involving 77,000 men ages 55 to 74. It concluded that while annual PSA screening led to diagnosis of more prostate cancers in a seven-year period, it did not reduce deaths from the cancer.

Two out of every five men whose prostate cancer is detected through a PSA test, one study found, have a slow-growing cancer that would never have posed any threat to their lives. Men with such cancers may then be left with permanent incontinence or impotence - common side effects of standard treatments such as radiation and surgery - to treat a cancer that they would have never known about without screening.

“Now I don’t feel that as a physician I’m obliged to bring up PSA testing,’’ said LeFevre, a family physician and professor of family and community medicine at the University of Missouri.

The American Cancer Society has taken a somewhat softer position. “We elected to say to men that we did not know whether or not PSA testing saved lives, but thought the best approach was for men and their health professionals to have a clear discussion, outlining the benefits and risks before embarking on a program of PSA testing,’’ Dr. Len Lichtenfeld, the group’s deputy chief medical officer, wrote in a blog post.

Dr. Jacques Carter, a primary care doctor at Beth Israel Deaconess Medical Center in Boston, said he is concerned that patients at higher risk for prostate cancer, such as those with a family history and African-American men, will no longer get tested because of the new guidance. He said he will continue to counsel African-American men in their 40s to start screening.

Johnson can be reached at cjohnson@globe.com; Kotz at dkotz@globe.com. Follow her on Twitter @debkotz2.

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