Prostate cancer screening called into question

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Screening for illness is based on a simple concept: catch the disease early and more timely treatment will (inevitably) lead to better outcomes. However, as with most things in life, things turn out to be not a clear-cut as they sometimes seem. Tests are not foolproof, of course. And sometimes tests can detect things that don’t necessarily matter. For example, mammography will inevitably detect breast cancers that are not destined to significantly compromise the quality or quantity of the life of the woman in whom it has been detected. What this means in this case is that women may be subjected to unnecessary debilitating and expensive treatment. You can read more about the issues surrounding breast cancer screening here and here.

The male counterpart of mammography is the PSA (prostate specific antigen) test – levels of which can go up when the prostate is affected by cancer. This test has been enthusiastically embraced by the American medical community, while here in the UK doctors have been more reticent about deploying this test. This might have something to do with the fact that running PSA tests and the treatment that may result is a potentially lucrative practice in the context of ostensibly-private system of medicine in the US.

In fact, this fact has recently been highlighted a one Dr Richard Ablin. Today’s British Medical Journal contains a piece which explores Dr Ablin’s many objections to PSA screening [1]. In fact, he thinks doctors should stop using it, a view he expressed in a recent New York Times article. What qualifies Dr Ablin to take such a broadside regarding PSA? Well, he discovered it.

Some of Dr Ablin’s reservations about PSA screening are:

1. It is not specific for cancer: the cut-off point for PSA is generally set at 4 ng/ml. 80 per cent of men with PSA values of 4-10 ng/ml actually have benign (non-cancerous) prostatic enlargement.

2. Even when it detects actual cancer, the test cannot be used to determine whether the cancer is slow-growing and non-life-threatening or more aggressive in type.

3. Evidence shows that for one life to be saved as a result of PSA screening, 48 men would have to be treated. This leaves 47 men who have had perhaps non-critical surgery, that can leave them impotent and maybe incontinent.

This last point reminded me of a client I saw recently who had, some time ago, been found to have a raised PSA. Prostate biopsy revealed genuine cancer, and he was offered (with different specialists) different treatments of varying aggressiveness for this. In all of this, though, doing nothing did not appear to be an option.

However, he was particularly concerned about the potential side-effects of treatment, and resolved to do some reading and research. In the end he elected not to have any conventional treatment. He actually ended up consulting a naturally-oriented doctor with a special interest in cancer.

The last I heard his PSA was back down in the normal range, with no sign of any further advancement in his disease. He’s had no adverse side-effects either. At this stage at least, it appears his decision to do nothing (regarding conventional treatment) was the right one.

Dr Ablin is scathing in his opinion of what drives PSA screening in the US. In ths BMJ piece today he is quoted as saying “It seems to me that financial motives have spurred a tsunami of testing,” adding “There’s an unbelievable industry behind this. Unfortunately we don’t practise evidence based medicine here; we do things and later rationalise what we’ve done by saying we thought it was the best thing to do at the time.”

The piece ends with this quote from Dr Ablin: “The medical community must confront reality and stop the inappropriate use of PSA screening. Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments.” It’s one man’s view, but one that appears to be gaining considerable momentum.


1. Hawkes N. Prostate screening: is the tide turning against the test? BMJ 2010;340:c1497

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