By RICHARD J. ABLIN
New York Times
March 9, 2010
http://www.nytimes.com/2010/03...opinion/10Ablin.html
Each year some 30 million American men undergo testing
for prostate-specific antigen, an enzyme made by the
prostate. Approved by the Food and Drug Administration
in 1994, the P.S.A. test is the most commonly used tool
for detecting prostate cancer.
The test's popularity has led to a hugely expensive
public health disaster. It's an issue I am painfully
familiar with - I discovered P.S.A. in 1970. As Congress
searches for ways to cut costs in our health care
system, a significant savings could come from changing
the way the antigen is used to screen for prostate
cancer.
Americans spend an enormous amount testing for prostate
cancer. The annual bill for P.S.A. screening is at least
$3 billion, with much of it paid for by Medicare and the
Veterans Administration.
Prostate cancer may get a lot of press, but consider the
numbers: American men have a 16 percent lifetime chance
of receiving a diagnosis of prostate cancer, but only a
3 percent chance of dying from it. That's because the
majority of prostate cancers grow slowly. In other
words, men lucky enough to reach old age are much more
likely to die with prostate cancer than to die of it.
Even then, the test is hardly more effective than a coin
toss. As I've been trying to make clear for many years
now, P.S.A. testing can't detect prostate cancer and,
more important, it can't distinguish between the two
types of prostate cancer - the one that will kill you
and the one that won't.
Instead, the test simply reveals how much of the
prostate antigen a man has in his blood. Infections,
over-the-counter drugs like ibuprofen, and benign
swelling of the prostate can all elevate a man's P.S.A.
levels, but none of these factors signals cancer. Men
with low readings might still harbor dangerous cancers,
while those with high readings might be completely
healthy.
In approving the procedure, the Food and Drug
Administration relied heavily on a study that showed
testing could detect 3.8 percent of prostate cancers,
which was a better rate than the standard method, a
digital rectal exam.
Still, 3.8 percent is a small number. Nevertheless,
especially in the early days of screening, men with a
reading over four nanograms per milliliter were sent for
painful prostate biopsies. If the biopsy showed any
signs of cancer, the patient was almost always pushed
into surgery, intensive radiation or other damaging
treatments.
The medical community is slowly turning against P.S.A.
screening. Last year, The New England Journal of
Medicine published results from the two largest studies
of the screening procedure, one in Europe and one in the
United States. The results from the American study show
that over a period of 7 to 10 years, screening did not
reduce the death rate in men 55 and over.
The European study showed a small decline in death
rates, but also found that 48 men would need to be
treated to save one life. That's 47 men who, in all
likelihood, can no longer function sexually or stay out
of the bathroom for long.
Numerous early screening proponents, including Thomas
Stamey, a well-known Stanford University urologist, have
come out against routine testing; last month, the
American Cancer Society urged more caution in using the
test. The American College of Preventive Medicine also
concluded that there was insufficient evidence to
recommend routine screening.
So why is it still used? Because drug companies continue
peddling the tests and advocacy groups push "prostate
cancer awareness" by encouraging men to get screened.
Shamefully, the American Urological Association still
recommends screening, while the National Cancer
Institute is vague on the issue, stating that the
evidence is unclear.
The federal panel empowered to evaluate cancer screening
tests, the Preventive Services Task Force, recently
recommended against P.S.A. screening for men aged 75 or
older. But the group has still not made a recommendation
either way for younger men.
Prostate-specific antigen testing does have a place.
After treatment for prostate cancer, for instance, a
rapidly rising score indicates a return of the disease.
And men with a family history of prostate cancer should
probably get tested regularly. If their score starts
skyrocketing, it could mean cancer.
But these uses are limited. Testing should absolutely
not be deployed to screen the entire population of men
over the age of 50, the outcome pushed by those who
stand to profit.
I never dreamed that my discovery four decades ago would
lead to such a profit-driven public health disaster. The
medical community must confront reality and stop the
inappropriate use of P.S.A. screening. Doing so would
save billions of dollars and rescue millions of men from
unnecessary, debilitating treatments.
Richard J. Ablin is a research professor of
immunobiology and pathology at the University of Arizona
College of Medicine and the president of the Robert
Benjamin Ablin Foundation for Cancer Research.
New York Times
March 9, 2010
http://www.nytimes.com/2010/03...opinion/10Ablin.html
Each year some 30 million American men undergo testing
for prostate-specific antigen, an enzyme made by the
prostate. Approved by the Food and Drug Administration
in 1994, the P.S.A. test is the most commonly used tool
for detecting prostate cancer.
The test's popularity has led to a hugely expensive
public health disaster. It's an issue I am painfully
familiar with - I discovered P.S.A. in 1970. As Congress
searches for ways to cut costs in our health care
system, a significant savings could come from changing
the way the antigen is used to screen for prostate
cancer.
Americans spend an enormous amount testing for prostate
cancer. The annual bill for P.S.A. screening is at least
$3 billion, with much of it paid for by Medicare and the
Veterans Administration.
Prostate cancer may get a lot of press, but consider the
numbers: American men have a 16 percent lifetime chance
of receiving a diagnosis of prostate cancer, but only a
3 percent chance of dying from it. That's because the
majority of prostate cancers grow slowly. In other
words, men lucky enough to reach old age are much more
likely to die with prostate cancer than to die of it.
Even then, the test is hardly more effective than a coin
toss. As I've been trying to make clear for many years
now, P.S.A. testing can't detect prostate cancer and,
more important, it can't distinguish between the two
types of prostate cancer - the one that will kill you
and the one that won't.
Instead, the test simply reveals how much of the
prostate antigen a man has in his blood. Infections,
over-the-counter drugs like ibuprofen, and benign
swelling of the prostate can all elevate a man's P.S.A.
levels, but none of these factors signals cancer. Men
with low readings might still harbor dangerous cancers,
while those with high readings might be completely
healthy.
In approving the procedure, the Food and Drug
Administration relied heavily on a study that showed
testing could detect 3.8 percent of prostate cancers,
which was a better rate than the standard method, a
digital rectal exam.
Still, 3.8 percent is a small number. Nevertheless,
especially in the early days of screening, men with a
reading over four nanograms per milliliter were sent for
painful prostate biopsies. If the biopsy showed any
signs of cancer, the patient was almost always pushed
into surgery, intensive radiation or other damaging
treatments.
The medical community is slowly turning against P.S.A.
screening. Last year, The New England Journal of
Medicine published results from the two largest studies
of the screening procedure, one in Europe and one in the
United States. The results from the American study show
that over a period of 7 to 10 years, screening did not
reduce the death rate in men 55 and over.
The European study showed a small decline in death
rates, but also found that 48 men would need to be
treated to save one life. That's 47 men who, in all
likelihood, can no longer function sexually or stay out
of the bathroom for long.
Numerous early screening proponents, including Thomas
Stamey, a well-known Stanford University urologist, have
come out against routine testing; last month, the
American Cancer Society urged more caution in using the
test. The American College of Preventive Medicine also
concluded that there was insufficient evidence to
recommend routine screening.
So why is it still used? Because drug companies continue
peddling the tests and advocacy groups push "prostate
cancer awareness" by encouraging men to get screened.
Shamefully, the American Urological Association still
recommends screening, while the National Cancer
Institute is vague on the issue, stating that the
evidence is unclear.
The federal panel empowered to evaluate cancer screening
tests, the Preventive Services Task Force, recently
recommended against P.S.A. screening for men aged 75 or
older. But the group has still not made a recommendation
either way for younger men.
Prostate-specific antigen testing does have a place.
After treatment for prostate cancer, for instance, a
rapidly rising score indicates a return of the disease.
And men with a family history of prostate cancer should
probably get tested regularly. If their score starts
skyrocketing, it could mean cancer.
But these uses are limited. Testing should absolutely
not be deployed to screen the entire population of men
over the age of 50, the outcome pushed by those who
stand to profit.
I never dreamed that my discovery four decades ago would
lead to such a profit-driven public health disaster. The
medical community must confront reality and stop the
inappropriate use of P.S.A. screening. Doing so would
save billions of dollars and rescue millions of men from
unnecessary, debilitating treatments.
Richard J. Ablin is a research professor of
immunobiology and pathology at the University of Arizona
College of Medicine and the president of the Robert
Benjamin Ablin Foundation for Cancer Research.
