There is so much confusion regarding the need for routine screening. Professionals disagree regarding the medical literature conclusions on this subject. Patients become confused because there are so much conflicting suggestions. Patients usually end up deciding to trust their physicians’ advice. This could be a reliable source, provided the physician is well read, and the information shared includes that ambiguity that is inherent in the practice of medicine.
My grandfather gave me a plaque that reads, ‘Don’t confuse me with the facts; my mind is already made up.’ My goal is not to persuade anyone whose mind is already made up. The medical literature presents many apparently contradicting opinions. Because human beings are unique creations, it is impossible to make a restrictive policy that accommodates all situations.
There has been recent debate regarding the benefit vs. risk of routine screening with the PSA blood test. In 2012 the US Preventive Task Force (USPTF) recommended against routine screening with the PSA. This decision was based upon the fact that many false positive tests resulted in surgical interventions that seemed to cause more harm than good. Proponents applauded this decision. The critics implied that this decision was driven by the Affordable Care Act and the need to save money. In 2013 the American Urological Association presented guidelines to routinely screen men between the ages of 55-69.
One of the most frequently cited journal articles regarding research was written by John Ioannidis, Why Most Published Research Findings Are False. Dr. Ioannidis is a Professor of Medicine and Health Research and Policy at Stanford University School of Medicine and a Professor of Statistics at Stanford University School of Humanities and Sciences. In this paper, Dr. Ioannidis describes the details regarding the fallacies in many published papers. This does not mean that we throw out all of the research findings. But it does mean that information needs to be filtered and applied individually.
Is PSA testing a good idea?
The ideal prostate screening test would be sensitive enough to determine if cancer existed. In addition, it would help to know the aggressiveness of the cancer. Not all cancers are aggressive. Prostate cancer is usually a slow growing cancer. The Prostate-Specific Antigen (PSA) test was discovered in the 1970s by Dr. Ablin. In an editorial in the New York Times on March 9, 2010, he said, “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 PSA 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 May 2012 the US Preventive Task of Preventive Services (USPTF) recommended against routine screening for prostate cancer with the PSA test. In fact, they gave the PSA test a ‘D’ recommendation, due to the potential negative challenges with those who have surgical intervention. Numerous early screening proponents, including Thomas Stamey, MD, a well-known Stanford University urologist, also came out against routine testing.
The American Cancer Society (ACS) urged caution in using the PSA test routinely. The American Cancer Society (ACS) recommends that men have a chance to make an informed decision with their health care provider about whether to be screened for prostate cancer. The decision should be made after getting information about the uncertainties, risks, and potential benefits of prostate cancer screening. The American College of Preventive Medicine concluded that there was insufficient evidence to recommend routine screening. Ironically, William Faloon, co-founder of Life Extension Magazine, a publication that promotes supplements and nutritional interventions, refuted the USPTF guidance and promotes routine PSA screening.
Five randomized controlled trials (two fair and three poor-quality) and two meta-analyses have evaluated the impact of PSA-based screening on prostate cancer mortality. After about 10 years, PSA-based screening is associated with the detection of additional cases of prostate cancer, but small to no reduction in prostate cancer-specific mortality.
Prostate-Specific Antigen-Based Screening for Prostate Cancer: An Evidence Update for the U.S. Preventive Services Task Force AHRQ Publication No. 12-05160-EF-1; October 2011
So one thing is very clear regarding PSA testing…there is very little agreement! There are newer tests being developed that may prove to be beneficial. Several newer tests seem to be more accurate than the PSA test, including:
Based upon all of these recommendations, the PSA may be the most useful test for now. It seems to be most useful during the ages of 55-69 years of age, especially for those with a family history of cancer. If the test is considered abnormal (>4.0), one may opt to pursue other diagnostic imaging (ultrasound, biopsy, bone scan). Some may decide to pursue surgery, chemo and/or radiation treatment. Others may opt to “watchful waiting” (do nothing and repeat testing later). A more recent option to consider is to have an evaluation of the PSA genetic potential to reflect an aggressive form of prostate cancer.
Options for following an abnormal PSA will vary according to individual and professional opinions. These options might include nerve sparing surgery, radiation implants, nutritional supplements, hormone medications, or ‘watchful waiting’ (doing nothing but repeating the test). Regardless of one’s decision, the following nutritional suggestions will help.
David MacDonald, DO
President, Liberty Health Group