[PSA test]
PSA Screening Test for Prostate Cancer:
An Interview with Otis Brawley, MD
By Maryann Napoli
(May 2003)
The prostate-specific antigen (PSA) screening test for early prostate cancer has
been surrounded by controversy ever since it was introduced over 15 years ago.
The test can indicate the presence of cancer, but many men have a form of
prostate cancer that will remain dormant or is so slow-growing that it will
never cause symptoms. Neither this test, nor any other can distinguish which
prostate cancer will become lethal. Furthermore, there is no proof that the
use of the PSA blood test to screen symptom-free men will spare anyone a
prostate cancer death, yet it is associated with a considerable amount of
unnecessary treatment with aftereffects that can be both severe and permanent.
All of the treatments for early prostate cancer carry the risk of impotence and
incontinence. In short, cancer researchers do not know whether PSA screening
saves more lives than it ruins.
Otis W. Brawley, MD, is the brains behind the ongoing National Cancer
Institute Prostate Cancer Prevention Trial, which is designed to answer
questions about the effectiveness of screening and the causes of prostate
cancer. After leaving the National Cancer Institute, Dr. Brawley became the
Director of the Georgia Cancer Center and Professor of Medicine, Oncology, and
Epidemiology at Emory University School of Medicine. He is interviewed about the
ever-increasing use of PSA screening in the face of so much uncertainty about
its value.
Napoli: Does the popularity of PSA screening concern you?
Dr. Brawley: First of all, I'm not against prostate cancer screening. I'm
against telling people that it is well established; and that it works; and that
it saves lives when the evidence that supports those statements simply does not
exist. I'm a tremendous supporter of the real American Cancer Society (ACS)
recommendation, which is: Within the physician-patient relationship, men should
be offered PSA screening and should be informed of the potential risks, as well
as the potential benefits and be allowed to make a choice.
Napoli: Do you think fully informing men about PSA screening happens very often?
Dr. Brawley: I think it rarely happens. Many doctors are uninformed, and that's
a big problem. My great concern is people being misled. I routinely follow the
prostate cancer screening recommendations of 18 organizations in the U.S.,
Canada, and Western Europe. The two most pro-screening recommendations are those
of the ACS and the American Urologic Association. Both of whom say it should be
offered to men; men should be informed of the potential risks and the potential
benefits; and they be allowed to make a choice. The ACS does not recommend that
men of normal risk be offered mass screening. There's a distinction between what
is done within a doctor/patient relationship at a doctor's office and mass
screening.
Napoli: What is the difference?
Dr. Brawley: Mass screening takes place at a booth at a mall where screening is
offered to anyone who comes by and wants screening. In the last few years, there
has been screening on the floor of the Republican National Convention, health
fairs at the mall, [TV] channel this or channel that will have a health fair
with prostate cancer screening. Yet there is no organization that endorses mass
screening because of the concern that you can't have informed consent.
Napoli: If policy makers aren't promoting the test, who is?
Dr. Brawley: The British Medical Journal recently published an article about how
several of the leading prostate cancer survivor organizations [based in the
U.S.] that do a lot of the pushing of screening are funded by the makers of the
PSA screening kits. And, indeed, [these survivor organizations] do things that
the Food and Drug Administration won't let the manufacturers do--like make
promises that there are only benefits from prostate cancer screening. Many of
these prostate survivor organizations that I'm critical of--that take drug
company money--offer mass screening.
Napoli: You were once quoted in The New York Times saying that 30-40% of men
whose cancers appear to have been confined to the prostate at diagnosis will
recur soon after treatment.
Dr. Brawley: Yes, this [brings up] one of the lies perpetrated about prostate
cancer. If you look at the prostate cancer outcomes from a huge study conducted
by the National Cancer Institute, close to 40% of men who undergo a radical
prostatectomy will have a PSA relapse within two years. This means that they had
disease that was outside of the prostate that was not obvious to the surgeon or
the pathologist. It means that if the man lives long enough, metastatic disease
will kill him.
Napoli: The public is always told that early detection is lifesaving. How true
do you think that is for prostate cancer?
Dr. Brawley: If you have a group of men diagnosed as a result of PSA screening,
30-40% don't need to know that they have prostate cancer because it's
meaningless in terms of risk to their health. And for somewhere between 30% and
40% of the men with prostate cancer, no matter what [treatment is given], the
disease is not curable. And then maybe there are about 20% who actually benefit.
Napoli: And there's no way to know which type of prostate cancer you have.
Dr. Brawley: That's right.
Napoli: What about African American men, who as a group, are at a particularly
high risk for prostate cancer? PSA testing is thought to be advisable for them
at an earlier age.
Dr. Brawley: The proportion of black men in Rocky Feuer's paper [for the Journal
of the National Cancer Institute] who don't need to know they have prostate
cancer was over 40%, compared to 30% of white guys. The reason it's higher for
black men is that they have so many other competing causes of death. The other
issue is this: It's a principle of cancer screening that, unfortunately, many of
the advocates of screening just don't comprehend, and that is, the more
aggressive cancers are less likely to benefit from screening. There are people
out there who say we must screen black men because they have more aggressive
prostate cancer. [These screening proponents] do not realize that they are
saying, in effect, because prostate cancer screening is less likely to benefit
black men, then we must screen black men.
Napoli: You recently published a medical journal article about informed consent
and the PSA test.
Dr. Brawley: Yes, the problem I have is that people are not open and honest
about all the controversies, and this extends to people being not open and
honest about the treatments, once prostate cancer is diagnosed. Men tend to get
railroaded toward radical prostatectomy or to external-beam radiation, or to
seed implants.
Napoli: Since there's no evidence that any one of these treatments is superior
to another or superior to no treatment, for that matter, where do you suggest
men go for unbiased information?
Dr. Brawley: First of all, I think we should tell men what is scientifically
known and what is scientifically not known and what is believed and label them
accordingly. [As for credible sources of information,] the National Cancer
Institute's PDQ treatment statements at
www.cancer.gov are good
[call 800/4-CANCER]. So is the ACS's information. And by the way, we at Emory
have figured out that if we screen 1,000 men at the North Lake Mall this coming
Saturday, we could bill Medicare and insurance companies for $4.9 million in
health care costs [for biopsies, tests, prostatectomies, etc]. But the real
money comes later--from the medical care the wife will get in the next three
years because Emory cares about her man, and from the money we get when he comes
to Emory's emergency room when he gets chest pain because we screened him three
years ago.
Napoli: You're saying that screening creates long-term customers. So, did Emory
Healthcare decide to go ahead with the free PSA screening on Saturday?
Dr. Brawley: No, we don't screen any more at Emory, once I became head of Cancer
Control. It bothered me, though, that my P.R. and money people could tell me how
much money we would make off screening, but nobody could tell me if we could
save one life. As a matter of fact, we could have estimated how many men we
would render impotent...but we didn't. It's a huge ethical issue.
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