The tragic trajectory

Thank you to Anne Katz for again raising the issue of prostate-specific antigen (PSA) screening for prostate cancer.¹

The most recent meta-analysis of PSA screening² showed no benefit of screening in 387 000 people. The Canadian Task Force on Preventive Health Care recommends against PSA screening (grade D, “fair evidence against”).³ The US Preventive Services Task Force recommends against screening.⁴ These are our people—family physicians, epidemiologists, and statisticians who have weighed the evidence fairly. So why do we persist in screening with PSA testing? The answer is pressure from outspoken and powerful advocates (ie, urologists); pressure from media and society groups whose enthusiasms have been stirred by crusading urologists; and pressure from patients, and especially from their spouses, who have been influenced by the media to see this as a simple issue with a simple right decision.

People see anyone who advises against or anyone who declines the test as lacking in courage in the “battle” against cancer. Foremost in the minds of patients and physicians alike is the unquestioned dogma that early detection is always and self-evidently an advantage in the treatment of any disease. To get across to people that, in the case of prostate cancer, later is better and not at all is better still is just too much of a stretch.

My practice contains many men who were stampeded into doing the test, having the biopsies, and having radical prostatectomies, and who are now left with substantial urinary and sexual dysfunction. Many have given up on their sex lives altogether. Maybe some lives were saved, but how would we know, as we cannot predict who will progress and who will not?

When doing periodic heath examinations I still try to present the pros and cons of PSA screening evenhandedly, but mostly I should save my breath—people just want it done. Variations on “my wife told me to do it” and “all the guys at work have done it” are the clinchers. Rarely does anyone decline the test.

So that is what we are up against, Anne Katz. Eventually men will engage with this issue, just as women did in the 1990s over hysterectomy. Our job as family physicians is to continue to present the evidence that aggressive treatment of prostate cancer offers little if any survival advantage over no treatment, that it entails the likelihood of erectile dysfunction and possibility of incontinence, and that therefore men should think carefully before doing the test.

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