Posted: Aug. 19, 2012 | 8:07 p.m.
American men, dying at the rate of about 30,000 a year from prostate cancer, need a better test to screen for the disease.
The U.S. Preventive Services Task Force, a panel of doctors that advises the government on cancer screenings and other ways to avoid disease, has come to that conclusion.
So have primary care doctors, urologists and prostate cancer specialists across the country.
What the task force and many practitioners don't agree on, however, is a May advisory of the task force, a recommendation against screening healthy men for prostate cancer using the prostate specific antigen, or PSA, blood test.
The test has long been a source of frustration for men and the physicians who treat them. A major criticism is that it causes hundreds of thousands of men to be needlessly treated for slow-growing cancer that doesn't pose a threat.
Relying on study findings that found that, at best, one man in every 1,000 given the PSA test may avoid death as a result of the screening, the panel concluded that the screening does far more harm than good. Of the same 1,000 men screened, two to three will have a treatment complication such as a blood clot, heart attack or stroke, or even death, and as many as 40 will have erectile dysfunction, urinary incontinence or both. As many as 40 more will suffer problems such as infection from a prostate biopsy.
While urologists in Southern Nevada acknowledge the PSA test has significant shortcomings - it can't differentiate between a slow- growing cancer that needn't be treated and a dangerous aggressive cancer - many of them cite different statistics that they believe show that screening is responsible for dramatically dropping the mortality rate of prostate cancer.
Some valley clinicians believe the task force recommendation may cause prostate cancer deaths to rise.
For Tony Crispino, a cancer survivor who heads the Las Vegas chapter of the UsTOO International prostate cancer support group, the heated controversy in the media over the recommendation - both former New York Mayor Rudy Giuliani and former New York Yankees manager Joe Torre swear their lives were saved by a PSA test - could be "very positive" for millions of men.
"It could lead to more education on testing," Crispino said before throwing out the first pitch before a Las Vegas 51s game in conjunction with the upcoming Prostate Cancer Awareness Month in September.
Fifty-five-year-old Brad Lipke, a Henderson Chevrolet sales coordinator suffering with stage-4 prostate cancer, agrees that the more attention the test gets, the better.
"I believe part of the problem with finding a good test is that men haven't talked about prostate cancer enough - they're embarrassed - so there isn't a sense of urgency like there is for women with breast cancer," he said before a recent appointment with Dr. Nicholas Vogelzang at Comprehensive Cancer Centers of Nevada.
Unlike Crispino, who says a PSA test led to treatment that saved his life, Lipke said screening didn't help him.
In 2007, he had a test that showed he was fine. But 11 months later, he was at the worst stage of prostate cancer.
"I don't see it as reliable," said Lipke, who prays Vogelzang can keep him alive to celebrate Christmas with his wife.
The PSA test measures the blood level of a protein that is produced by the prostate gland, a walnut-sized structure that makes up part of a man's reproductive system.
A high PSA test score - one above 4 nanograms per milliliter - typically leads to a painful biopsy in which a dozen or so tissue samples are taken to determine whether cancer has begun to grow in a man's prostate.
Dr. Dale Carrison, chief of staff at University Medical Center, knows the pain. Three times he had a high PSA and subsequent biopsies. There was no cancer.
"I can't say I believe in the test's reliability," he said.
Research shows the experiences of Carrison and Lipke are common. About two-thirds of men with higher PSA levels don't have cancer - even an over-the-counter drug such as ibuprofen can sometimes elevate the level - while about one-third of men with low levels that are usually considered "safe" do have the disease.
Many doctors, including prostate cancer specialist Vogelzang and Las Vegas urologist Dr. Sheldon Freedman, say that although the PSA is imperfect, they still believe it's largely responsible for the results of a National Cancer Institute study showing that prostate cancer mortality decreased 40 percent in the United States between 1992 and 2007.
"How else can you explain it?" Vogelzang said.
But the task force noted screening didn't become widespread until the mid-to-late 1990s. And it explained that a potential mortality benefit from screening doesn't occur for up to 10 years, making it "very unlikely" screening alone caused the drop in deaths. Many factors, including treatment advances, could have played a role, the task force said.
It's unclear how great an effect the recommendation against screening is having in Las Vegas. Some physicians say they now don't include it in physicals for healthy patients. Still others say they discuss the option with patients.
Dr. David Park, a family physician associated with the Touro University Nevada College of Osteopathic Medicine, said he no longer uses the test on healthy patients older than 50 because he agrees with the task force. He did say, however, that if there is family history of the disease, he will encourage the test.
As Dr. Thomas Hunt, a family physician tied to the University of Nevada School of Medicine, examined 72-year-old Andrew Murphy recently, he said that after discussing the test's pros and cons, he leaves the decision on testing up to the patient.
Las Vegas urologist Joseph Candela says the PSA test is the best tool clinicians have for screening.
"If we don't use the test, we'll have a higher mortality rate from prostate cancer," he said.
There is no evidence that an ultrasound or a digital rectal exam, in which a doctor puts a lubricated, gloved finger into the rectum to check for growths in the prostate gland, are effective diagnostic screening tools by themselves either, though urologists say that with the PSA test they better help detect cancers.
Urgency and frequency of urinating are poor indicators of prostate cancer, since the cause is often benign.
The more you talk with Nevadans, the more you realize it is indelibly etched into the American consciousness that early detection is the key to a positive outcome with cancer.
What has surely made many people think that way is the Pap test, which reduces the risk of dying of cervical cancer by as close to 100 percent as possible. By comparison, mammography reduces the risk of death from breast cancer by 25 percent.
Not one person questioned as they stopped at a cancer information table set up at a recent Las Vegas 51s game knew that researchers found the PSA test so ineffective. Most shared the belief of 60-year-old Steve Pelton, who said it was clear to him that the best way to beat prostate cancer was to find it early.
But Dr. Otis Brawley, chief medical officer at the American Cancer Society, said prostate cancer is unlike other cancers, with as many as 60 percent of prostate cancers never needing to be found, because they grow so slowly that men are likely to die of something else long before their prostate tumor becomes threatening.
Though three-quarters of men older than 80 and a third of men between ages 40 and 60 have cancer cells in their prostate, data show that men have just a 2.8 percent lifetime risk of dying from the disease.
Brawley estimates that during the last two decades 1 million American men have received unnecessary treatments causing side effects - some life-threatening - because of mass prostate cancer screening.
For those diagnosed with prostate cancer, treatments range from radiation or surgery to active surveillance, an increasingly common recommendation that involves monitoring the cancer instead of treatment.
Many men and their wives get anxious, however, and can't handle the less-invasive approach. The American Cancer Society estimates nearly 250,000 prostate cancer cases will be diagnosed in 2012 with the majority resulting in costly treatment.
Urologist Freedman said he is now using a new gene-based urine test called PCA3 in conjunction with a PSA test to more accurately determine whether a patient needs a biopsy. The new test may also analyze how aggressive a cancer is after a positive biopsy.
To cancer patient Pelton, in the last throes of prostate cancer, new, more accurate tests won't come soon enough.
"But if my talking to you about how important it is to get an accurate test helps make it happen," he said, "I'll think I've made a difference."
Contact reporter Paul Harasim at pharasim@reviewjournal.com or 702-387-2908.
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