News that former President Joseph Biden has advanced prostate cancer has revived long-standing questions about the benefits versus the harms of a blood test that screens for the most commonly diagnosed cancer among men in the U.S.
Prostate-specific antigen, or PSA, screening tests are an imperfect tool for detecting prostate cancer, doctors and public health experts say.
Part of the problem is identifying and treating aggressive cancers like Biden's while not unnecessarily treating men with slow-growing cancers unlikely to sicken them. Autopsies found the disease to be so widespread that more than one-third of white men and half of Black men in their 70s had prostate cancers that would never do any harm.
"PSA testing alone leaves a lot to be desired as a cancer screening test," said radiation oncologist Dr. Brent Rose, an associate professor at the University of California, San Diego, School of Medicine.
The test measures the level of PSA, a protein produced by normal as well as malignant prostate gland cells, in the blood. Elevated PSA can be a marker for cancer. It also can signal a false positive or an inactive cancer, triggering a painful biopsy, and leading to overtreatment with punishing side effects, including impotence, incontinence and bowel dysfunction.
"PSA screening is beneficial," Rose said. "There are risks, though, and so it is a personal decision whether or not to do PSA screening."
The key is to target and treat aggressive cancers while waiting and watching cancers that might never become troublesome, Rose and other oncologists told NPR. Physicians have been walking this tightrope since they began regularly using PSA tests to screen for prostate cancer in healthy men in the 1990s. There is no other test that effectively screens for prostate cancer — the second deadliest cancer for American men, oncologists said.
A history of conflicting guidance
Attempts to balance the possible harms against the number of lives saved have led to two decades of fluctuating – and confusing – public health guidelines on PSA screening. In 2012, the U.S. Preventive Services Task Force advised against any screening, only to issue a watered-down recommendation in 2018 that men ages 55 to 69 discuss screening with their health care providers. Various physicians' groups offer conflicting guidance for this age group.
In its advice to older men, however, the U.S. Preventive Services Task Force has been somewhat more consistent. In 2008, the independent of national experts recommended men 75 and older not be screened, and since 2018, the has advised against screening men 70 and older.
Biden, 82, apparently followed the guidance. He last had a PSA screening test in 2014, when he was 71 or 72 years old, a spokesman said.
For men between the ages of 55 and 69, the task force recommends talking to their health care providers about their preferences before deciding whether to get a PSA test. It classifies the recommendation as Grade C, which means it offers only a small benefit and insurers may not cover it.
Finding the time to have a conversation about a topic as complicated as the value of prostate-cancer screening can be challenging for most primary-care physicians, oncologists interviewed for this story said. And while some men might welcome what's called "shared decision-making," others find it agonizing. Still, the only advice for men for now is to talk the issue over carefully with their doctors.
The case for the PSA test
Dr. Alicia Morgans, a genitourinary medical oncologist at the Dana-Farber Cancer Institute in Boston, recognizes the problem and hopes that the task force will address it in new guidelines, which it is currently drafting. In August, she met with the volunteer in her role as chair of the medical advisory board for the advocacy group Zero Prostate Cancer.
Morgans believes the current guidance was based on a flawed clinical trial. It concluded that men screened with PSA tests were no less likely to die of prostate cancer than men assigned to a group that was not screened. But the results were muddied because nearly 90% of the men in the control group had at least one PSA test before or during the trial, she said.
Morgans would like to see the recommendation beefed up so more men get screened for prostate cancer and Black men and men with a family history, who are more vulnerable get screened earlier.
"I take care of people who have very advanced prostate cancer, as well as some people who have curable prostate cancer," she said, "so my perspective is really skewed by the fact that I really want to make that diagnosis when things are curable."
So does Dr. Matthew Cooperberg, a urologic oncologist and a professor at the University of California, San Francisco. He has pushed to rename early-stage prostate cancer in part to ease the stress of a cancer diagnosis. One possible name, "acinar neoplasm," describes an abnormal growth but one lacking the potential to spread or kill. Cooperberg also advocates monitoring men with elevated PSAs before rushing to biopsy their prostates.
"Men should get PSA testing in midlife with the goal of finding aggressive prostate cancer," he said. "If we find low-grade disease along the way, whether or not we call it cancer, we should not treat it. We just monitor it with active surveillance. If we do that, we can erase this cancer."
A new approach to prostate cancer screening emerges
Dr. Tyler Seibert, a radiation oncologist and associate professor at the University of California, San Diego, is not as optimistic about eliminating prostate cancer. But he too is dedicated to finding ways to identify the bad prostate cancers and treating only them.
When doctors first began doing PSA screening tests, he said, "there was a flawed assumption that was implicit that if you find any kind of prostate cancer, you must treat that kind of prostate cancer aggressively," he said. "Many of them would never have harmed the patient."
A new era in prostate-cancer screening has arrived, Seibert believes. Today, instead of men immediately having their prostates biopsied when they get an elevated PSA test, he and an increasing number of prostate-cancer specialists recommend first getting an MRI and, when possible, watching and waiting.
"For these patients with low-risk prostate cancer, we have really strong evidence that we can follow them closely, and they basically can just carry on with their life," he said.
Not everyone is comfortable with getting periodic blood tests to see if their PSA might be rising and they might indeed need cancer treatment, Seibert acknowledged. But most of his patients do become comfortable with the protocol, he said.
"Every time you get that blood test, you're kind of a little bit nervous," he said. "If you can tolerate that, and you don't think that it's going to be causing you too much anxiety, then screening makes a lot of sense."
Ronnie Cohen is freelance health journalist based in the San Francisco Bay Area.
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