Why I decided to still get a PSA test

I'm a believer in scientific research. I worked as a health planner for over ten years. I wrote a well-received analysis, "Quality of life in allocating health care resources." I understand that much medical care is wasteful, unneeded, and ineffective.

Nonetheless, at my annual physical last week this 63 year old guy still decided to get a PSA test, which is used to detect prostate cancer. Only problem is, the test isn't very effective. In October the United States Preventive Services Task Force recommended against getting the test, in most cases. 

Healthy men should no longer receive a P.S.A. blood test to screen for prostate cancer because the test does not save lives over all and often leads to more tests and treatments that needlessly cause pain, impotence and incontinence in many, a key government health panel has decided.

Reading an article about this in our newspaper, I'd pretty much decided to pass on a PSA test when it came time for my annual physical. If the test causes more harm than good, why get one?

However, I'm fortunate to have a family doctor who open-mindedly discusses options with her patients. We talked about the pros and cons of me getting a PSA test for five minutes or so. In the end, I said "Hey, why not? I'll get a PSA test this year, like I have in the past."

This was what shaped my reasoning: (1) My insurance would pay for the test. (2) I could either ignore the results of the test, or I could pay attention to the results. (3) Either way -- ignore or pay attention -- I'd have more information if I got the PSA test, than if I didn't.

You can read the draft recommendation from the Preventive Services Task Force here. lt seems solid.

Experts at the Oregon Health Science University, a short drive up I-5 from where I live, affirmed the Task Force's review of the literature on PSA test effectiveness. So I'm convinced that, given current knowledge, for most men there's no compelling reason to get a PSA test.

But there's also no compelling reason not to.

It's up to the individual, like me, who is as capable of deciding whether to get a PSA test as to how much importance should be given to the results. Meaning, just as I could have decided to pass on a PSA test, so I could pass on any further diagnosing if the test came back with a positive result.

In the exam room I told my doctor, "The main argument against getting a PSA test seems to be that a positive result often leads to unnecessary treatment, with nasty side effects (impotence, incontinence). However, this implies that patients are helpless to resist the Medical Treatment Machine, which sucks them in against their will."

So I thought, why not? 

A positive test result would worry me, but not nearly so much as it would have before I learned that 80% of positive PSA results are false. Thus usually it makes sense to take a positive result lightly, or even to ignore it completely.

Again, I realized that I could either ignore the PSA test by not getting one, or I could get the test and then ignore the results. (Which turned out to be negative, by the way.) I trusted that my doctor and I could deal with a positive result wisely -- not rushing into a biopsy or surgery without a very good reason.

This attitude is in line with a recent "Perspective" piece in the New England Journal of Medicine: "One Man at a Time -- Resolving the PSA Controversy."

The U.S. Preventive Services Task Force recently released a draft recommendation on screening for prostate cancer, designed for primary care physicians and health systems, and has opened it for public comment until November 8, 2011. After completing a rigorous evidence review, the task force decided to recommend against screening for prostate-specific antigen (PSA), concluding that there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. This grade D recommendation applies to healthy men of all ages, regardless of race or family history. The task force's suggestion for practice for grade D interventions is to “discourage the use of this service.”

...Our perspective is that this evidence of a possible small but finite benefit from the largest trial would best support a grade C recommendation for men 55 to 69 years of age. With a grade C recommendation, the task force would be recommending “against routinely providing the service” while indicating that “there may be considerations that support providing the service in an individual patient” and stipulating that “there would need to be at least moderate certainty that the net benefit is small.” The task force's suggestions for practice in the case of a grade C recommendation include the suggestion that they “offer/provide this service only if other considerations support offering or providing the service in an individual patient.”

A grade C recommendation would allow the patient to be involved in the decision to skip or choose a PSA screening test, after a discussion with a primary care provider about the magnitude of the known harms and the potential for some benefit. The patient could then provide his perspective on how he views the trade-off. Weighing the pros and cons to make a decision about PSA screening is an individual process, and different well-informed men will make different decisions. 

Absolutely.

This is a middle way: recognizing that on the whole, the PSA test isn't called for; but if an individual patient wants one after considering the pros and cons, he should be able to get one.

Comments

[Willie R]

PSA is short for Prostate Specific Antigen. An antigen is a substance that promotes the development of antibodies. When antibodies are being produced, it means that there is some unwanted process occurring, which, in the case of the prostate, would be an unregulated proliferation of cells more commonly known as a tumor. Therefore, if PSA levels are increased beyond a certain amount, it is fairly certain that cancer nastiness is right around the corner.
It's a cheap test that involves drawing a few extra milliliters of blood. In all probability, the chemical analysis of the blood is automated and costs practically nothing. The PSA test is trivial, but an elevated PSA level is not.
Physicians these days take every opportunity to investigate borderline blood chemistry results. They refuse to take any chances - they want to know why certain components of the blood are elevated. My own doctor completely turned my life upside down last year when he refused to give me clearance for surgery because I had borderline high levels of "monocytes" in my blood. A high monocyte level is most often associated with leukemia, and it cost $8000 for a bone marrow biopsy to find out that I did not have leukemia. That little exercise delayed my surgery for six months. My new doctor recently reviewed my medical records and told me that I have had high monocyte levels for many years. Go figure.
High PSA levels are not 100 percent indicative of cancer, but it puts a fellow in that undesirable neighborhood. There does not seem to be a valid reason to immediately jump into biopsies based upon borderline results.

[Blogger Brian]

Willie R, not only are you correct that high PSA levels are not 100 percent indicative of answer, the situation is much more uncertain than that.

As mentioned in this post, 80% of tests that come back with a high PSA level are false positives. Meaning, the patient doesn't have a tumor. So 4 times out of 5, the PSA test is wrong.

[tucson]

All these diagnostics and tests can be a blessing or a curse as Willie R demonstrated.

Prostate cancer is usually slow growing and can remain localized in the gland itself. (this is not to say there are not aggressive prostate cancers).

If you get a high PSA reading or even a diagnosis of cancer, chances are you will live another 20 years or so without any action being taken. If you are 60 or 70 years old that puts you at about the end of your life anyway.

So, I say ignore the test and live 'till you die.

Oh, you say you want to live to be 100? Have you ever seen a centenarian whose health condition you envied?