Dr. Deepak A. Kapoor is president of Advanced Urology Centers of New York and president of the Large Urology Group Practice Association.
Recently one of our patients made a decision that may well cost him his life. John Smith (not his real name) is a 51-year-old who had an elevated prostate specific antigen (PSA) during a routine prostate cancer screening exam. After a blood test confirmed our concerns, he had a biopsy — and, though he had no other symptoms, the patient was found to have multiple areas of high-grade prostate cancer. After obtaining several opinions, he scheduled minimally invasive robotic surgery to have his prostate removed.
But then, the United States Preventive Service Task Force issued recommendations that PSA screening is unnecessary, saying that asymptomatic men whose cancer is detected via screening are unlikely to die from their disease. Based on this, Smith canceled his surgery. And despite our attempts to explain that ongoing observation is not appropriate for his aggressive disease, he is adamant in his refusal to have treatment.
The true tragedy is that the task force, which is chaired by a pediatrician and includes no specialists who treat prostate cancer, made this recommendation based on controversial and contradictory studies and inexplicably ignored data on prostate cancer incidence and mortality.
In 2009, this same group suggested mammograms were unnecessary for women younger than 50, and recommended against teaching women to do breast self-exams. Due to public outrage, these recommendations were almost immediately retracted. To avoid further embarrassment at that time, the panel decided not to fully release its prostate cancer screening recommendations, and then just issued a limited opinion suggesting PSA screening was not warranted for patients older than 75. Since then, only one additional screening study has been published, which demonstrated a 44 percent decrease in prostate cancer death rates among Swedish men who received screening compared with those who did not.
Without question, prostate cancer can be a slow-growing disease for some men. But it is fatal for many others, with the National Cancer Institute predicting nearly 34,000 prostate cancer deaths this year. It is the second-leading cause of cancer deaths for American men, after lung cancer.
But we have made enormous strides in treating this disease. Before PSA screening, the 10- year survival for prostate cancer was 53 percent; it’s now over 97 percent. Since the advent of widespread PSA screening in the early to mid 1990s, the death rate from prostate cancer has decreased by nearly 40 percent, while during that interval the incidence of prostate cancer is virtually unchanged. We are diagnosing prostate cancer earlier, and saving lives.
The task force suggests that no one without symptoms be screened, but every urologist knows this is a grave mistake. By the time prostate cancer is symptomatic, the opportunity for cure is lost. Screening, though not perfect, provides patients with information that they can use to make the best decisions for themselves. To suggest that no man have this information because of concerns regarding treatment that they may never receive is a scientific bait-and-switch of the worst order.
Shortly after release of the task force recommendations, President Barack Obama, after discussion with his doctor, chose to have PSA screening. These recommendations open the door for government and third-party payers to stop covering this test, meaning that the average man may be unable to make that same choice. And men like Mr. Smith who don’t show symptoms might never be able to make an informed decision about treatment until it is too late. Every patient should be able to do just what the president did — make a screening decision with his own doctor, and not have that choice made for him by insurance executives or government bureaucrats.
Massive public outcry saved breast cancer screening for women, and studies show that screening efficiency for prostate cancer is similar to that for breast cancer. Those of us concerned with men’s health must make our voices heard to prevent these premature and ill-advised recommendations from ever being enforced. That will help save the lives of thousands of Mr. Smiths nationwide.