DURHAM — The national medical panel that set off a firestorm last year with draft recommendations advising against men of all ages using a common screening test for prostate cancer made the advice formal Monday.
The final version of the controversial U.S. Preventive Services Task Force guidelines about the so-called PSA test with new supporting data was published online Monday afternoon in the Annals of Internal Medicine.
This time it faced an instant rebuttal in the same major health journal via an editorial written by a group of prominent experts, including the head of the Duke Prostate Center.
There are a number of problems, but in my opinion the biggest mistake they made was not taking into account the suffering experienced by men with advanced prostate cancer, said Dr. Judd Moul, co-author of the rebuttal, a Duke professor of surgery and widely published prostate researcher.
Lack of effective screening used to mean doctors often got cases that were too advanced to effectively treat, he said.
Such cases often involve cancer that has spread to the bones, which can be torturously painful, he said, and federally funded research has shown that the screening has cut the number of such cases.
I dont want to see us go back to the bad old days before PSA screening, because it was just terrible, he said.
The National Cancer Center estimates that about 241,000 men will be diagnosed with prostate disease this year and 28,200 will die from it.
The task force had announced last fall that it believed healthy men shouldnt routinely get the blood test, which looks for high levels of a certain protein that can signal the presence of prostate cancer.
It generates a high rate of false positive results, and the task force said that its review of various studies showed that while it does help detect more cancers, it has little or no effect on the rate of death from the disease.
The false positives, say PSA critics, frequently lead to unnecessary treatment that can badly harm or even kill patients who might well have survived the cancer with little or no problem.
Prostate cancer is rare among men younger than 45, though, and about two-thirds of the cases grow slowly. That means many men who contract it, even if left untreated, will show no symptoms for decades and die of other causes. Treatment can include radiation and surgery, which can lead to issues such as incontinence, impotence and even death.
Based on analysis of studies that have appeared since the draft recommendations, the new task force report says that screening with the PSA test could save the lives of perhaps as many as one man for every 1,000 tested.
Harm, including death
Complications from treatment, though, could lead to serious harm to as many as 43 more, including the death of one man out of every 3,000 tested.
Before getting a PSA, all men deserve to know what the science tells us about PSA screening: There is a very small potential benefit and significant potential harms, said Task Force Co-Chairman Dr. Michael LeFevre, of the University of Missouri School of Medicine, in a news release.
The task force is an independent group of health care professionals that gives medical advice to the federal government and the public, too, on preventing health problems.
Its recommendations do not apply to men showing symptoms of prostate cancer. In such cases, the PSA test is diagnostic rather than a screen.
The authors of the rebuttal published Monday wrote that there were significant flaws in the methods that the task force used to evaluate prostate cancer research.
They also wrote that the task forces report could lead health insurance companies and even Medicare to refuse to reimburse for the cost of the screening.
Every man should get it
Moul said he firmly believes that PSA screening is a vitally important tool. He believes all men should get it at age 40 for a baseline sense of how vigilant they should be about the disease.
A low level, for example, could mean that further screenings could be spread out to every five years, while a moderate level could mean testing every year or two is a good idea.
Many of Mouls patients agree.
Gerald Whisenhunt, 75, of Goldsboro said Monday that he had just been tested and given a clean bill of health.
That wasnt the case two years ago when an elevated PSA level led to a biopsy that found he was suffering from an aggressive form of cancer. He quickly got a successful treatment, including surgery, at Duke.
If insurers stop funding regular PSA screening, hed pay for his own son to get it, Whisenhunt said.
Every man should get it, he said. I just dont see how you can take the chance not to, because it would be just like playing Russian roulette.
Also blasting the recommendations was the American Urological Association, which issued a statement Monday saying that it was outraged and that the task force was doing men a great disservice disparaging what is now the only widely available test for prostate cancer.
In another article that appeared in the same journal, Dr. Otis Brawley, chief medical and scientific officer at the American Cancer Society, said over-diagnosis had made the screening appear to be more effective at saving lives than it really was.
Just because a man was screened and treated doesnt mean he would have died of the disease, Brawley said.
Many people have a blind faith in early detection of cancer and subsequent aggressive medical intervention whenever cancer is found, Brawley wrote. There is little appreciation of the harms that screening and medical interventions can cause.