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What is role of PSA in prostate cancer?

Roanoke Times

10-18-17

Dear Mike,

You may recall, when I was still working, all those debates we had about the PSA. ... You were a pain in the neck with the way you favored including the PSA in the yearly physical, and I felt - and there were many others back then who agreed with me - it should not be included. I really thought it was "junk science." ... Well, I wish I listened to your logic. I retired five years ago and moved to Chicago to be with my son and his family. I find myself diagnosed with stage 4 prostate cancer.

My frustration is that I refused to have a PSA for years during my yearly physical because I was convinced the PSA test would do more harm than good to me. I looked at the studies and decided that I didn't want to chase down every red herring the PSA result could generate so I ignored it. Then, my back started to hurt really bad, and my PSA was through the roof.

I know you still write for the paper, and it's a great thing you do for people, so tell them what happened to me and tell the guys to order the PSA and do whatever it takes not to have to go through this if it can be avoided.

My thoughts and prayers are with you, my friend. If anyone I know will fight and beat this, it's you. I am so sad to hear what you're going through, but you know as well as I that there are things that can be done for people in your situation.

The issue of the PSA test, which measures proteins produced by the prostate gland, has cut both ways for decades, and doing a PSA is not a guarantee of anything.

We know of cases where the PSA failed to identify cancer. And, conversely, of many unnecessary blood tests and biopsies, not to mention unnecessary patient anxiety, that have been generated. When it works, the test has value, and when it doesn't, it casts doubt.

For many years, I have been an advocate of using PSA tests until a more definitive test becomes available. I am biased in that the PSA led to the diagnosis of my prostate cancer six years ago before the typical symptoms of the cancer presented themselves. That result led to a biopsy and ultimate treatment.

One of the objections to the PSA has always been the number of unnecessary biopsies it could generate. Yet if we look at the diagnostic yield of many biopsies - from breast biopsies to skin biopsies to colon polyp biopsies - the number of normal results found could, in retrospect, render the biopsy "unnecessary." Yet the tests are accepted as part and parcel of good practice, and, in competent hands, the rate of complications is low.

The path to diagnosing this disease is not always as straightforward as in my case, but given the potentially serious nature of the disease, it's worth the effort. As a practicing physician, I have had many cases where the test result correctly prompted further work-up that offered at least some choices for patients and their families. To be sure, other times we went off on an expensive wild goose chase.

Only recently have the data begun to define the PSA's place in clinical practice. By "recently," I refer to a study led by Dr. Ruth Etzioni at the Fred Hutchinson Cancer Research Center in Seattle, Washington, published Sept. 4 in the online edition of the Annals of Internal Medicine. The study found that PSA screening can "significantly reduce the risk of prostate cancer death."

However, some people take issue over diagnostic error and overtreatment. Those are justifiable concerns, but what is the "business" of medicine if not to save lives? The history of our profession is replete with procedures, medicines and technology that have been less than perfect but, in their day, made their contribution to improving the human condition. With time and hard work, we got better and built on the missteps of the past.

After 40 years in this field, I believe the PSA test is a stepping stone to better technology. Until we reach that point, we still have to try to save lives.

Some say that statistically the number of saved lives is small. To that, I say no number of saved lives is small. Some say that if everybody thought like that, the health care system would go broke. That is the same rhetoric used right before we started widespread screening colonoscopies for colon cancer, screening mammograms for breast cancer and screening chest CT scans for lung cancer. Now, these studies are considered good practice, and nobody discusses their cost.

Indeed, the aforementioned tests have their flaws - as all studies do - but we still order them. Given the prevalence of these cancers in our society, the expense is clearly justified.

Equally, given the prevalence of prostate cancer in men, I feel the test should be done as part of the yearly physical in the appropriate age group. Medicine is not always neat and tidy. It is often imperfect. But we do what we can with what we have.

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