Skipping the prostate test can kill

Guest Editorial
(This editorial is being reprinted from USA Today, where it was first published.)

Robert Reich, the 4-foot, 10-inch former secretary of Labor, is fond of saying that on average he and basketball goliath Shaquille O’Neal are 6 feet tall, which he notes is both statistically interesting and personally useless.

The same can be said of a controversial new finding that, on average, the simple blood test that detects prostate cancer does more harm than good. If you have undetected cancer, the average outcome is irrelevant. Skipping the test can kill you.

That logic seems lost on the U.S. Preventive Services Task Force, which recommended last week that because of its findings, the prostate-specific antigen (PSA) test should no longer be routinely given to men over 50, as it generally has been for the past two decades. Instead, men should be counseled first about the consequences of treatment for prostate cancer, with the obvious goal of deterring them from getting the test.

There’s no disputing that treatment carries serious risks. Surgery and radiation, the most
common treatments after a biopsy confirms cancer, can cause urinary incontinence and impotence. Both are usually temporary and treatable, but they’re still complications no man would dismiss.

Nor is there any question that some men are treated more aggressively than necessary. Prostate cancer is often slow-growing, particularly in older men, and monitoring is a common option. But when people hear they have cancer, the natural reaction is, “Get it out.” Doctors too often oblige, even when “watchful waiting” would be a smarter course.

The more significant consideration, though, is that all those factors come into play long after the PSA test, if at all. The only risks from the test itself are stress and the discomfort and rare complications of the subsequent biopsy.

So aren’t patients better advised to get the facts first and then the counseling if needed, rather than being discouraged from finding out whether they have cancer in the first place? The task force’s approach seems based on the theory that what you don’t know can’t hurt you. Well, it can.

For now, the effect of the task force’s decision is minimal. It did not suggest that men should be deprived of the test, and urologists loudly objected to the recommendation, so presumably many will ignore it. But the task force’s advisories influence insurance coverage, which could some day exclude the test — an outcome that would fit the task force’s goals.

The last time the task force reached a controversial conclusion like this, in 2009, the government intervened, assuring women that mammograms would be covered despite a task force conclusion that questioned their value. Private insurers followed. In that instance, the task force argued that most women in their 40s don’t need routine annual testing and that older women could cut back to every other year. Then, as now, the task force’s concern was excessive follow-up procedures, and its thinking was just as flawed.

Statistical averages are fine fodder for academic discussions. But for the 50-plus male, Reich’s warning about how little they mean on a personal level is better medical advice than forgoing an annual PSA test.