Wellbeing
Some of us are already here while hundreds are still to arrive. Yet, in spite of all the progress that has been made recently, PSA-bashing still rears its ugly head.
The Advance on Washington week is about to begin. It’s an entire week of scientific, advocacy and government outreach meetings and events planned to forward new treatments and raise awareness and funding support for prostate cancer so we can move closer to our goal of ending death and suffering as a result of this disease.
However, as if on cue, another round of PSA-bashing began this weekend in this Saturday’s New York Times, Editorial Section with the publication of “Is Newer Better? Not Always.” Some folks never get it… the PSA is not a cancer-specific test. It is part of a diagnostic process that can help identify a number of problems that might be brewing in a man’s prostate and direct physicians to the proper treatments for their patients. If the problem turns out to be cancer, there are a host of treatment options, including proactive surveillance, depending on the severity of the cancer.
Rather than burying this tool, we should indeed be praising it–it has saved thousands of lives, including mine, through the years.
Despite the approximately 40 percent decline in the death rate during the past several years made possible with earlier diagnosis and treatment and better treatments, critics still beat out the same hackneyed, overused and incorrect arguments against PSA testing. Guess what? With the incidence and death rates on the rise the first time in many years as a result of the growing number of baby boomers aging up, we need early diagnostics, including the PSA test, more than ever.
With 2.5 million American men and their families currently facing this disease, more than 218,000 new cases projected to come on line, and 32,000 men projected to die from prostate cancer this year, I dare anyone to look any of us in our eye and make the argument against PSA testing. A rapid, near doubling of my PSA in a year’s time caught my cancer. And though my cancer is now metastatic, the PSA will continue to aid in saving my life as it is used to monitor the effectiveness of my treatments and signal my physicians should there be an unwanted recurrence.
The time has come to stop bullying a valuable tool for patients and to take a look at the advances that are being made in developing better diagnostics and treatments. Critics’ energies would be better spent if they joined us in Washington this week, came up to speed on the very real progress that is being made and joining our call for accelerated progress.
________________________________________________________________
The following are some responses from other leaders in the prostate cancer community:
Talk about a broken record, repeated again and again until people start thinking it’s the truth only because they keep hearing it! The problem you describe – over-treatment – is NOT a reason to discourage testing for prostate cancer. As President of the National Alliance of State Prostate Cancer Coalitions, I can assure you that we do not encourage over-treatment or treatment when it is not indicated (i.e. when active surveillance is more appropriate for that particular patient). On the other hand, we have men dying miserable prostate cancer deaths (to a greater degree than women dying of breast cancer) each year because those men were not given a chance for cure of their lethal, aggressive disease. Dr. Ablin has stated in my presence that no one is ever cured of prostate cancer. Really? Tell that to the men we know and represent who are years-long survivors from their initial diagnosis and treatment. Early diagnosis of potentially lethal prostate cancer is key.
Please avoid letting the naysayers replace the voice of reason. The answer (and one that NASPCC is working on) is to establish a disconnect between diagnosis and automatic treatment. That way, men with disease that will likely kill them without treatment can receive the necessary medical care to avoid such a death, and men with clinically insignificant cancer can choose to be watched. The choice cannot be made, however, if a man is not tested and is thus denied a diagnosis. You do a disservice to the thousands of men who read your paper if you convince them that testing is a bad and unhealthy idea.
Merel Grey Nissenbeg, Esq., President, NASPCC
An editorial commentary printed in today’s New York Times is focused on an estimate by the US Congressional Budget Office that “an astonishing half or more of the increased spending for health care in recent decades is due to technological, surgical and clinical advances.”
In making the point that many advances in health care are clinically valuable and economically cost effective and that some aren’t, the editorial implies that the PSA test is an example of a technological advance that is neither clinically valuable nor economically cost effective. (To be fair, the article does not state this explicitly.) The Times uses the OpEd written by Richard Ablin some months ago as documentation to support this viewpoint.
Whatever one may happen to think about the value of the PSA test as a mass, population-based screening test for prostate cancer, what is most certainly true is that any fault lies not with the test itself but with how we use the test and how we apply the results when we get them. From a time in the late 1980s and early 1990s, when the PSA test was, most certainly, an extremely valuable test to detect risk for prostate cancer in a previously untested population (US males of 50 and over) at significant risk for prostate cancer because they had never been tested, it has become a test promoted as an annual screening mechanism for any man over 40 years of age — and the data to support this broadest of possible uses is definitely on shaky ground. However, we can not afford to throw out the baby with the bath water.
For men with known risk factors (age, ethnicity, genetic predisposition, family history), the PSA test is the only way we have to monitor that risk. Indeed, preliminary data from a large study just published in Europe suggests strongly that the PSA test is a very appropriate screening test for prostate cancer in men known to have the BRCA1 and BRCA2 genes. By contrast, it is becoming evident that most men of 40 and over do not need an annual PSA test (just as they don’t need an annual screening test for colon cancer, where the annual screening period is normally every 5 years).
There are three things that need to happen for Americans to get a better grasp on the value of PSA testing:
◦The first is a better appreciation for risk. If you have no good reason to believe you are at risk for prostate cancer, it is open to question whether you need a PSA test annually. What we do need to to know is whether the appropriate frequency for PSA testing in men with no known risk factor is every 2, 3, 4 or 5 years. (Recent data from the Göteborg study in Sweden certainly suggest that every 2 years is effective, but we really don’t know whether that is the best possible option.)
◦The second is more sensible responses to the results of PSA testing. What are the data that should trigger the need for a biopsy that is liable to find not just any prostate cancer at any age, but any prostate cancer that is likely to be clinically significant in the lifetime of a specific patient.
◦The third is a widely accepted, data-based mangement paradigm for early stage, localized prostate cancer that is inclusive of the very real value of expectant management, so that patients with apparently low- and very low-risk disease are not rushed into the operating room or the radiation suite when it would be better medical practice to monitor them for the possibility of higher risk for at least a period of time.
Whether or not we are “over-diagnosing” prostate cancer is an arguable question (particularly if you take the viewpoint that the diagnosis of the condition is entirely justifiable). What most certainly is the case, however, is that we have been over-treating men with low- and very low-risk disease. Excessive use of the PSA test may well be a factor that has lead to over-treatment, but that over-treatment is something that we can control. Rather that just “trashing” the PSA test, we need to address the more fundamental problem which is a reflection of the decisions we make about the need for a PSA test in the first place in a specific individual at a specific point in time and how we react to the test results when we get them.
And of course what we really need more than anything else is a much better test for risk of clinically significant prostate cancer — just as soon as is humanly possible.
E. Michael D. Scott, Prostate Cancer International
The Advance on Washington week is about to begin. It’s an entire week of scientific, advocacy and government outreach meetings and events planned to forward new treatments and raise awareness and funding support for prostate cancer so we can move closer to our goal of ending death and suffering as a result of this disease.
However, as if on cue, another round of PSA-bashing began this weekend in this Saturday’s New York Times, Editorial Section with the publication of “Is Newer Better? Not Always.” Some folks never get it… the PSA is not a cancer-specific test. It is part of a diagnostic process that can help identify a number of problems that might be brewing in a man’s prostate and direct physicians to the proper treatments for their patients. If the problem turns out to be cancer, there are a host of treatment options, including proactive surveillance, depending on the severity of the cancer.
Rather than burying this tool, we should indeed be praising it–it has saved thousands of lives, including mine, through the years.
Despite the approximately 40 percent decline in the death rate during the past several years made possible with earlier diagnosis and treatment and better treatments, critics still beat out the same hackneyed, overused and incorrect arguments against PSA testing. Guess what? With the incidence and death rates on the rise the first time in many years as a result of the growing number of baby boomers aging up, we need early diagnostics, including the PSA test, more than ever.
With 2.5 million American men and their families currently facing this disease, more than 218,000 new cases projected to come on line, and 32,000 men projected to die from prostate cancer this year, I dare anyone to look any of us in our eye and make the argument against PSA testing. A rapid, near doubling of my PSA in a year’s time caught my cancer. And though my cancer is now metastatic, the PSA will continue to aid in saving my life as it is used to monitor the effectiveness of my treatments and signal my physicians should there be an unwanted recurrence.
The time has come to stop bullying a valuable tool for patients and to take a look at the advances that are being made in developing better diagnostics and treatments. Critics’ energies would be better spent if they joined us in Washington this week, came up to speed on the very real progress that is being made and joining our call for accelerated progress.
________________________________________________________________
The following are some responses from other leaders in the prostate cancer community:
Talk about a broken record, repeated again and again until people start thinking it’s the truth only because they keep hearing it! The problem you describe – over-treatment – is NOT a reason to discourage testing for prostate cancer. As President of the National Alliance of State Prostate Cancer Coalitions, I can assure you that we do not encourage over-treatment or treatment when it is not indicated (i.e. when active surveillance is more appropriate for that particular patient). On the other hand, we have men dying miserable prostate cancer deaths (to a greater degree than women dying of breast cancer) each year because those men were not given a chance for cure of their lethal, aggressive disease. Dr. Ablin has stated in my presence that no one is ever cured of prostate cancer. Really? Tell that to the men we know and represent who are years-long survivors from their initial diagnosis and treatment. Early diagnosis of potentially lethal prostate cancer is key.
Please avoid letting the naysayers replace the voice of reason. The answer (and one that NASPCC is working on) is to establish a disconnect between diagnosis and automatic treatment. That way, men with disease that will likely kill them without treatment can receive the necessary medical care to avoid such a death, and men with clinically insignificant cancer can choose to be watched. The choice cannot be made, however, if a man is not tested and is thus denied a diagnosis. You do a disservice to the thousands of men who read your paper if you convince them that testing is a bad and unhealthy idea.
Merel Grey Nissenbeg, Esq., President, NASPCC
An editorial commentary printed in today’s New York Times is focused on an estimate by the US Congressional Budget Office that “an astonishing half or more of the increased spending for health care in recent decades is due to technological, surgical and clinical advances.”
In making the point that many advances in health care are clinically valuable and economically cost effective and that some aren’t, the editorial implies that the PSA test is an example of a technological advance that is neither clinically valuable nor economically cost effective. (To be fair, the article does not state this explicitly.) The Times uses the OpEd written by Richard Ablin some months ago as documentation to support this viewpoint.
Whatever one may happen to think about the value of the PSA test as a mass, population-based screening test for prostate cancer, what is most certainly true is that any fault lies not with the test itself but with how we use the test and how we apply the results when we get them. From a time in the late 1980s and early 1990s, when the PSA test was, most certainly, an extremely valuable test to detect risk for prostate cancer in a previously untested population (US males of 50 and over) at significant risk for prostate cancer because they had never been tested, it has become a test promoted as an annual screening mechanism for any man over 40 years of age — and the data to support this broadest of possible uses is definitely on shaky ground. However, we can not afford to throw out the baby with the bath water.
For men with known risk factors (age, ethnicity, genetic predisposition, family history), the PSA test is the only way we have to monitor that risk. Indeed, preliminary data from a large study just published in Europe suggests strongly that the PSA test is a very appropriate screening test for prostate cancer in men known to have the BRCA1 and BRCA2 genes. By contrast, it is becoming evident that most men of 40 and over do not need an annual PSA test (just as they don’t need an annual screening test for colon cancer, where the annual screening period is normally every 5 years).
There are three things that need to happen for Americans to get a better grasp on the value of PSA testing:
◦The first is a better appreciation for risk. If you have no good reason to believe you are at risk for prostate cancer, it is open to question whether you need a PSA test annually. What we do need to to know is whether the appropriate frequency for PSA testing in men with no known risk factor is every 2, 3, 4 or 5 years. (Recent data from the Göteborg study in Sweden certainly suggest that every 2 years is effective, but we really don’t know whether that is the best possible option.)
◦The second is more sensible responses to the results of PSA testing. What are the data that should trigger the need for a biopsy that is liable to find not just any prostate cancer at any age, but any prostate cancer that is likely to be clinically significant in the lifetime of a specific patient.
◦The third is a widely accepted, data-based mangement paradigm for early stage, localized prostate cancer that is inclusive of the very real value of expectant management, so that patients with apparently low- and very low-risk disease are not rushed into the operating room or the radiation suite when it would be better medical practice to monitor them for the possibility of higher risk for at least a period of time.
Whether or not we are “over-diagnosing” prostate cancer is an arguable question (particularly if you take the viewpoint that the diagnosis of the condition is entirely justifiable). What most certainly is the case, however, is that we have been over-treating men with low- and very low-risk disease. Excessive use of the PSA test may well be a factor that has lead to over-treatment, but that over-treatment is something that we can control. Rather that just “trashing” the PSA test, we need to address the more fundamental problem which is a reflection of the decisions we make about the need for a PSA test in the first place in a specific individual at a specific point in time and how we react to the test results when we get them.
And of course what we really need more than anything else is a much better test for risk of clinically significant prostate cancer — just as soon as is humanly possible.
E. Michael D. Scott, Prostate Cancer International