New advice stokes debate on test for prostate cancer

Robert Braam, a retired transportation engineer, has been talking up the value of regular checkups since he learned last month -- to his surprise -- that he has prostate cancer. He had no symptoms.

So Braam questions the new recommendation of a government medical panel discounting prostate tests for older men.

The U.S Preventive Services Task Force, an independent panel of experts that reviews clinical practices for the federal government, said routine prostate screening for men 75 and older wasn't necessary. And it also said more evidence is needed to determine whether men under 75 benefit.

"I want people to get a PSA test," said Braam, 64, of Raleigh, who is exploring his treatment options. "It saved my neck, as far as I'm concerned."

The task force's recommendation reignites an intense disagreement among physicians and patients about the value of the prostate-specific antigen test, or PSA test. The blood analysis is used in combination with digital rectal exams to screen for prostate cancer -- the most common cancer among men.

An estimated 186,000 cases will be diagnosed this year in the United States, with 5,050 in North Carolina, according to the American Cancer Society. And prostate cancer is the second-leading cause of cancer deaths among men.

The blood test, which measures a protein produced by the prostate gland, has been widely used since the 1990s to screen for prostate cancer in men 50 and older. A high PSA level or sudden jump in the number might indicate cancer and invites further testing.

"This task force just renews the fiery debate on what is the role of PSA," said Dr. Raj Pruthi, director of urologic oncology at the UNC Lineberger Comprehensive Cancer Center. "I don't think we understand it enough to write it off and say it's no good. I don't think it's the answer to everything, either."

Despite its widespread use, the PSA test remains controversial. The National Cancer Institute says it's not clear whether the benefits of PSA screening outweigh the risks of follow-up diagnostic tests and cancer treatment. The disease is often slow moving, leading some to argue that the cure may be worse than the disease.

The institute is conducting a long-term study to determine whether screening reduces the number of deaths.

One of the test's drawbacks is it often detects small, slow-growing cancers that would never become life-threatening. That puts patients at risk for complications from unnecessary treatment such as surgery or radiation. Some men who would never have died of prostate cancer undergo surgery that leaves them impotent or incontinent.

Testing can do harm

Dr. Russell Harris, a professor at the UNC-CH School of Medicine who served on the task force and voted for the recommendation, said the panel tried to weigh the benefits and harms of screening.

"By testing in situations where you shouldn't test and following it up with treatment, you actually can hurt people with screening tests," Harris said.

For example, Harris said, if you screen 100 men in their 60s and 70s, about 15 to 20 will have a positive PSA test. A follow-up biopsy on those with high readings would find three to five men with prostate cancer.

"Of those three to five who have prostate cancer, certainly no more than one would have died from the cancer," Harris said. "The other men had prostate cancer under the microscope, but it doesn't grow fast. We are certainly going to be over-treating a number of men."

As men get older, their prostates enlarge normally, and the PSA levels goes up. So PSA levels are less useful for detecting cancer in older men, Harris said. And prostate surgery can irreparably alter the quality of some men's lives.