Defending the Prostate Cancer Blood Test
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Given rising medical costs, physicians are increasingly urged to practice "evidence-based" medicine. The recently updated guidelines for prostate-specific antigen, or PSA, screening for prostate cancer ["U.S. Panel Questions Prostate Screening," front page, Aug. 5] illustrate the promise but also the pitfalls of incomplete evidence as well as the importance of individual considerations.
I am a general internist, and, in the past three years, I have known two men (not my patients), one in his 80s, the other in his 90s, who were not screened and who developed florid prostate cancer with multiple painful metastases to their bones. The younger man had other health problems, but his cancer responded to hormone treatment that significantly improved the quality of his remaining years. The older man, otherwise perfectly healthy and in full possession of his faculties, died a painful and almost certainly premature death.
Guidelines are designed for groups and are based on probabilities. Prostate cancer is usually a slowly developing disease. If every man over 75 were screened, and everyone who tested positive were treated, we would be likely to spend more money on prostate cancer than it warrants. However, the PSA test is easy and cheap. For the two men I mentioned, timely testing could have made all the difference.
CAROLINE POPLIN
Bethesda
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If it is indeed true that the PSA test does more harm than good for men over 75, it seems like an obfuscation to blame the harm on the test. Surely the fault lies with the quality of decisions made on the basis of that test. Are we to blame the patients for those decisions or the physicians who advise them? Perhaps a panel of physicians is reluctant to criticize colleagues.
The PSA test is just a first step. Further testing, such as a tissue biopsy (or perhaps even genetic markers?), may provide a better profile of the cancer and a more reliable indicator of the risk from inaction. My experience as a prostate cancer survivor tells me that the implication that "surgical biopsies" are unnecessary and painful greatly exaggerates the effect of this simple office procedure and devalues the considerable information it produces for making treatment decisions.
RICHARD H. BALL
Annandale
