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Why the debate? Prostate cancer screening saves lives

Health Forum

Monday, June 10, 2002

By Carl Frankel

Retired Gen. Norman Schwarzkopf said it best when diagnosed with prostate cancer -- "You cannot sit back and do nothing because you'll never have perfect intelligence on the enemy...Get on with it."

Prostate cancer is the most commonly diagnosed malignancy in American men. It is curable if diagnosed early. Early detection is the key.

About 30,000 men will die from it this year alone and one out of every 18 of those deaths will be of a Pennsylvania resident, ranking the state fifth in both of prostate cancer incidence and deaths. That's why Pittsburghers over 45 don't need another excuse to avoid taking care of their health.

But the argument against the use of the prostate specific antigen blood test for detecting prostate cancer has provided that excuse -- pitting public health officials and primary care physicians, who claim there is no evidence of PSA success beyond a reasonable doubt, against many urologists who ask why a 27 percent decline in prostate cancer mortalities in the past five years isn't evidence enough.

Despite American Cancer Society and American Urological Association guidelines that encourage doctors to offer a PSA test and a digital rectal exam while discussing the risks of the disease, too many doctors lean toward discouraging the test, focusing on misplaced convictions that the test discovers insignificant tumors and that it doesn't save lives.

Physicians who have deferred or waffled on PSA testing are losing their licenses and seeing their malpractice insurance carriers pay out millions of dollars to bereaved families.

In a November 2001 wrongful death suit, a widow was awarded $3 million in a case in which the doctor in question "did not tell the patient about [the high PSA level] or recommend further testing or follow up visits."

A study at Long Beach Community Cancer Center of 48 such prostate cancer malpractice cases determined that, of the 22 awards totaling over $8.4 million, roughly $7.5 million "could have been avoided if PSA screening and diagnostic guidelines . . . had been followed."

These cases have become legal benchmarks as the PSA debate has moved from the doctor's office into the courthouse. They should come as a warning to science and public health policy officials across the country: If you continue to delay a decision on PSA, lawyers and lawmakers will make it for you.

Urologists will tell you that, despite imperfections, the PSA test has changed the prostate cancer diagnostic landscape. Before it, nearly three out of four men diagnosed with the disease were in the late stages -- when prostate cancer is neither readily treatable nor curable. The advent of screening has inverted that statistic, giving men a fighting chance. Regional studies support that early detection reduces mortality. One study in Austria shows that prostate cancer mortalities were markedly reduced with widespread PSA screening.

Even though newer blood tests help clarify the likelihood of cancer when PSA is abnormal, we still need more research to determine better models for early detection. But should we doom the thousands of men who could die waiting up to 14 years for the results of a randomized trial to determine "perfect intelligence" on the PSA? With so many lives in the balance, how much evidence do we need to convince us that prostate cancer is our enemy, not the test that so often detects it in time to permit a cure?

Men over the age of 50 -- and even younger if they are at higher risk of prostate cancer (African Americans and men with family histories of the disease) should "get on with it." Set aside the excuses and resolve to be tested every year.

Carl Frankel, an advocate for the National Prostate Cancer Coalition, is retired general counsel for the United Steel Workers of America and a prostate cancer survivor. He lives in Point Breeze.

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