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Healthy men told to skip prostate test

Panel underscores risks of PSA exam

A government panel recommended Monday that healthy men skip a widely used screening test for prostate cancer, concluding the harm caused by the PSA blood test outweighed its benefits in all age groups.

Based on evidence from two large randomized trials, the lifesaving benefits of screening were “at best very small’’ and were offset by overdiagnosis and overtreatment of nonlethal cancers, the US Preventive Services Task Force determined.

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“Our most optimistic estimate is that 1 out of 1,000 men screened will avoid dying from prostate cancer’’ because of early detection via the PSA test, said Dr. Michael LeFevre, co-vice chairman of the task force. “We’re not saying it’s zero. We’re leaving the window open for at least a small benefit.’’

That benefit, he added, must be stacked against a near doubling in the likelihood of being diagnosed with prostate cancer and having side effects from radiation or surgical treatments. He said 40 out of 1,000 men screened are left with permanent disabilities from their treatment, such as urinary incontinence or impotence, and almost all have slow-growing cancers that would not have been fatal.

Whether doctors and patients will follow the advice is unclear. Groups representing cancer doctors and patients objected to the recommendation, and a top official of the American Cancer Society said physicians by and large do a poor job of discussing the PSA test’s benefits and risks with patients.

The panel of independent primary care and public health specialists had said in 2008 that PSA testing was not advisable for men 75 and older but that evidence was inconclusive on its merits for younger men. That recommendation has not led to a drop in PSA screening among older men, according to research published last month in the Journal of the American Medical Association. Now the panel has extended its recommendation against PSA screening to all ages.

Many of those who treat prostate cancer - or who have had it themselves - argue that comparing a life saved with treatment side effects, however disabling, is like comparing apples with oranges.

“It’s hard to understand where they’re coming from,’’ said Dr. Anthony D’Amico, chief of genitourinary radiation oncology at Brigham and Women’s Hospital. In an editorial he coauthored in the Annals of Internal Medicine, where the new recommendations were published, D’Amico argued that the task force relied too heavily on data from a flawed study and failed to consider making separate recommendations for men in high-risk groups, such as those with a family history of prostate cancer and African-Americans, who have a two to three times greater risk of dying of the cancer than white men.

The task force, 16 primary care physicians and public health experts with no financial interests in tests or treatments, issues screening and other preventive health recommendations that tend to be more conservative than those of medical societies - composed mostly of specialists who treat diseases detected through screening - or patient advocacy groups.

In 2009, its expert panel came under a barrage of fire when it veered against nearly every American medical organization and stopped recommending routine mammograms for women in their 40s; the recommendation advised women to speak to their doctors about the risks and benefits before deciding.

The political fallout from that surprise downgrade led to specific language in the federal health care legislation last year mandating free coverage of mammograms in women 40 and older and led Congress to demand more transparency in the task force’s decision-making.

For PSA testing, the panel issued draft recommendations in October and invited comments, though the final language did not change much. (PSA testing is not one of the free preventive services required under the federal health law.)

The American Cancer Society has no plans to alter its advice - advising men to discuss the benefits and risks with their doctors before making a decision - but its chief medical officer, Dr. Otis Brawley, said he agreed with the task force.

“I think their process is exactly where it ought to be,’’ Brawley said. “It removes those people who have emotional, ideological, or financial conflicts of interest’’ from being on the panel. Doctors and hospitals, which get paid for performing follow-up biopsies and treatments that result from screening, have a strong interest in seeing as many men screened as possible, he added.

In Massachusetts, several hospitals offered free PSA tests and digital rectal exams during “prostate cancer awareness week’’ in September. A charity called Zero sends vans throughout the country to offer free screening and says on its website, “110,000 men tested.’’ The American Urological Association, representing urologists who treat prostate cancer, is listed as a partner on Zero’s website.

Jamie Bearse, chief operating officer of Zero, said each van has two doctors who provide educational materials outlining the full risks and benefits of prostate cancer screening; men with elevated PSA levels are referred for follow-up exams to whichever hospital Zero partners with in a particular town.

Former New England Patriots player Mike Haynes, a paid spokesman for the urological association, said he was diagnosed with prostate cancer in 2008, at age 55, after getting a free PSA test at an NFL event sponsored by the urological association. He said he was not told about any of the risks, such as false positive results, unnecessary biopsies, and overtreatment of slow-growing cancers. His elevated PSA and subsequent biopsy revealed a stage 1, slow-growing cancer, and “one of my options was watchful waiting, but my immediate reaction was let’s get it out of my system.’’

He considers himself lucky, however, in that the only side effect of surgery was a few months of urinary incontinence.

The urological association’s president, Dr. Sushil Lacy, said PSA screening has evolved since Haynes was screened and that men are now better educated during free campaigns. But Brawley said it is nearly impossible to have a real discussion about the risks and benefits outside of a physician-patient relationship - and all too often, even within one.

Haynes said his primary care physician had been performing PSA screening on him for years without even telling him.

“I think the task force came down harsh with their new recommendation,’’ said Brawley, “because we have definite evidence that informed decision-making isn’t happening.’’

Dr. Michael Barry, a primary care physician at Massachusetts General Hospital and president of the Boston-based Informed Medical Decisions Foundation, said he broaches PSA screening with his patients in their 50s and 60s, discussing the risks and benefits, and will continue to do so. “Although the benefit is small, the magnitude is in the eye of the beholder,’’ he said.

Deborah Kotz can be reached at dkotz@globe.com.
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