Tuesday, October 11, 2011

PSA Politics

“Wait until your Dad sees this.  He will go nuts!”

That was the comment to a family member in reaction to a New York Times article over this past weekend.  I was the “Dad” in question, and the article reported the latest government assessment of the Prostate-Specific Antigen (PSA) test.

As part of a physical exam, Americans typically get blood drawn to check for levels of cholesterol, glucose, etc.  Our culture considers these tests routine.  However, if you are a male over the age of 50, you might consider getting a PSA test.  It requires no additional effort on your part, and can tell whether or not your prostate is operating in a “normal” fashion.

Unfortunately, the PSA test has become controversial.  The U. S. Preventive Services Task Force (USPSTF) recommends against it. A draft statement issued today (available for comment until 11/8/2011) makes this contention: “There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.”

Richard J. Ablin, a research professor who discovered this cancer screening tool, characterizes his discovery as a “public health disaster.”

I don’t agree.  Let me offer some personal perspective.

In 1997, I was 50 years old and had a PSA test done with my annual physical.  My level came back at 1.4.  Normal is between 0.0 and 4.0 ng/mL, so it was no problem.  Eleven years later, in October of 2008, the test showed my PSA level at 2.8, still within normal range.  In January of 2010, my level came back at 4.0.  My Primary Care Physician (PCP) counseled, “Get thee to a specialist!”

While my PSA level was still within normal range, I had experienced a dramatic rise within the space of 15 months.  That is a danger signal, and my PCP sensed that something was not right.

The urology clinic where I ended up did an “ultrasensitive” PSA test.  The level came back at 3.91, validating the earlier results.  I scheduled a biopsy for February 11, 2010.

A little background on biopsy of the prostate:  It is more involved than it sounds.  Twelve (or more) needles are sequentially injected into the prostate to retrieve tissue samples from the left, right, top, bottom and middle of the prostate.  The idea is to try to map where cancer might be located within the prostate capsule.  It could be on just the left side, or maybe just at the base.  The extent of the cancer then gets graded and staged so that you have an expectation of whether aggressive treatment is needed.

On February 16, 2010 I received the news:  I had prostatic adenocarcinoma in five of the twelve samples from the biopsy.

The problem with prostate cancer is that it is asymptomatic.  You feel fine.  The only thing that is “wrong” is that you have some abnormal readings in your blood test.  It is deceptive in this way. People don’t die from prostate cancer.  They die from adenocarcinoma that originates in the prostate, is untreated, and ends up moving to the skeletal structure or some other organ in the body that is critical to sustaining life.  It is there that you experience the symptoms.  When that organ succumbs, the disease is fatal.

I had some time to think about all of this.  The initial determination was that I had Stage II cancer.  The tumors were still contained within the prostate. The cancer was too advanced to simply cut it away from the prostate, but if I could kill the prostate, the cancer would be killed as well.

How to kill the prostate?  The choices were to remove it or radiate it.  I chose to have it removed, simply for emotional reasons.  I wanted the cancerous prostate out of my body, sitting in a Petri dish somewhere.  There it could do no harm.

On 3/17/2010, I had my prostatectomy, done through a robotic procedure that removed the prostate and seminal vesicles.  The subsequent pathology indicated that the surgical margins were clean, with no evidence of malignancy.  That was the good news.  The bad news was that when the prostate was closely examined, the diagnosis was upgraded to Stage III adenocarcinoma, based on the tumor extending slightly beyond the prostate capsule.

There was a slight chance that metastasis had begun, but even that had a bright side.  When I now get a PSA test, the reading comes back at <.01 ng/mL.  That means the removal of the prostate got rid of the primary source of the cancer.  If a subsequent PSA reading comes back at a higher level, I will know that it is due to adenocarcinoma being located somewhere else in my body.  The PSA test thus becomes a tumor marker.

I’m relating my experience to give you an idea of the advances that have been made in this area of oncology in the last thirty years, and how a PSA test is used.  Prostate cancer in men is like breast cancer in women.  It is an affliction that is best treated upon early detection.  The absence of an abnormal PSA is like the absence of a lump in the breast.  It is reaffirming.

So what does all of this have to do with politics?  Healthcare and politics are becoming inescapably entwined in our culture.  The USPSTF makes its negative recommendation and suddenly PSA tests face the prospect of not being a covered healthcare benefit.  The benefit of early detection ends up being associated with political favoritism.

It is almost criminal that we pass a healthcare law where people with strong affiliations to the Democratic Party are granted exemptions from the law.  Those of us in the non-Democrat rank and file must be medically sophisticated and have the resources to choose an early detection tool and pay for it without government support.  The benefits of the past thirty years of research in prostate cancer accrue to those with a Democratic Party allegiance while the rest of us are instructed to wait until we experience full-blown symptoms and our only treatment choices might be palliative care or hospice.

Is it possible the political calculus is that non-Democrat males will end up dying sooner?  Could this be a hidden motive behind universal health coverage?  Those of us on the universal plan end up receiving “Voodoo Healthcare” where advances in medicine are withheld by government fiat under the rubric of protecting us from our perceived medical anxieties.

This is pure speculation, but if our culture adopted a healthcare system where Republicans were given special exemptions, there would be immediate outrage.  “Occupy Wall Street” is our current political spectacle, but imagine how protests against Voodoo Healthcare would appear.  “Voodoo Denver” or “Voodoo San Diego” would feature protesters at major hospitals staging “die-ins” to highlight the attenuation of human life that would be part and parcel of universal healthcare.  It wouldn’t be pretty.

I’ve got to ask this final question: Is it possible Sarah was right?
UPDATE 10/12/2011:
Here is a good follow-up article in The New York Times by Tara Parker-Pope.  The comments indicate this is an area of medicine where patient choice should figure prominently in the treatment.  It makes it even harder to understand why a governmental organization feels compelled to side with a particular point of view.  Aren't there more important things that should occupy the time of the USPSTF?

UPDATE 10/15/2011:
A blog post at Ricochet by "Western Chauvinist" continues to stir the pot.  Note the comments by "Dr. Bean" (Albert Fuchs, MD of Beverly Hills, California).  Dr. Fuchs deceptively explains why facing early death is preferable to managing non-life threatening discomforts.  He also stipulates that results of a PSA test can be "false-positive PSAs, meaning abnormal PSAs but no cancer."  The implication is not that another PSA test will be performed to verify the results, but that a biopsy must follow.

While that might very well occur, I think most people will be like me and get another confirming test before undergoing the biopsy.  When pathology of the samples from the biopsy either confirms the existence of cancer or not, that is not a "false-positive" problem with the PSA test.  Rather, it is a result from further testing.  To characterize the PSA test as suffering from a "false-positive" problem is like saying a five-day weather forcast is a "false-positive" because subsequent observations refine that forecast and provide additional detail.

UPDATE 5/22/2012:
The U.S. Preventive Services Task Force has reached its final decision:

"The Task Force concludes that many men are harmed as a result of prostate cancer screening and few, if any, benefit.  The USPSTF recommends against the service."

UPDATE 6/17/2012:
Diane Carmen has a thoughtful analysis of the issue in The Denver Post this weekend.  Dr. Richard Augspurger had a companion piece that features this quote:

The U.S. Preventive Services Task Force recently recommended against routine use of the prostate specific antigen (PSA) blood test to diagnose prostate cancer.  This recommendation was given despite significant opposition from urologists, oncologists, patients and advocacy groups.  No urologists or medical oncologists who regularly treat prostate cancer participated in the recommendation.

Why would it be important for the USPSTF to exclude urologists and oncologists?

UPDATE 11/19/2015:
The New York Times notes that early detection of prostate cancer is declining in the United States:

Fewer men are being screened for prostate cancer, and fewer early-stage cases are being detected, according to two studies published Tuesday in The Journal of the American Medical Association. The number of cases has dropped not because the disease is becoming less common but because there is less effort to find it, the researchers said. The declines in both screening and incidence “could have significant public health implications,” the authors of one of the studies wrote, but they added that it was too soon to tell whether the changes would affect death rates from the disease.

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  1. Funny, I thought it was a Republican plot to save money on those of us who need to use Medicare to pay for diagnosis/treatment. The USPS Task Force was implemented under Reagan.

    Whatever is going on, it isn't good. The PSA test is all we have at the moment.

    Stay well!

  2. Thanks, Anonymous.

    I agree with your comment. Let's abandon the PSA test when we've got something better, not before.