A man's right to know
A new study is raising valid questions about the screening and
treatment of prostate cancer. Less testing, however, is not the
answer.
A Times Editorial
Published May 29, 2004

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A new study on prostate cancer screening has renewed a useful debate
about what men should know and when and how they should be treated.
Oddly enough, though, some health experts are arguing that the study,
which found an alarming number of older men with serious cancer not
caught through the blood tests, suggests there should be less testing
and not more. Their logic is unhealthy.

The study, reported in the New England Journal of Medicine, raises
questions about the range currently considered normal. The researchers
performed biopsies on the prostates of 2,950 men, ages 62 to 91, whose
level of prostate specific antigen was measured at below 4.0 nanograms
per milliliter of blood - which is considered safe. But the biopsies
revealed cancer in 449 of the men and aggressive cancer in 67 of them.

The conclusion one would draw is more obvious than the course of
corrective action. The threshold is so high that it misses nearly one
in seven older men who take the test, but some of these men may end up
not needing treatment or even a biopsy. The reason is that some forms
of prostate cancer are not pernicious, and some forms of treatment can
cause impotence, incontinence and other complications. Biopsies
themselves can sometimes lead to bleeding or infection.

Ned Cologne, chairman of the U.S. Preventive Services Task Force, puts
it this way: "We are missing these prostate cancers, but we still
don't have an answer to the fundamental question, which is: If we
found them and treated them, would we make men live longer? That's
that missing piece of evidence."

Cologne's point is an important one, but not relevant to the test. We
know that early detection helps in fighting all forms of cancer, and
that the rate of prostate cancer has declined since the advent of PSA
blood tests (though other factors, such as improved treatment,
certainly contribute). So whether the medical community should use
these results to lower the threshold at which biopsies are routinely
ordered is a fair question. Whether prostate cancer in general is too
aggressively treated is also a source of continuing concern. But the
notion that blood test results, in themselves, can be harmful is
paternalistic at best.

Prostate cancer kills roughly 29,000 men every year, second only to
lung cancer, and men have a right to know. The PSA test is far from
perfect, to be sure, but it provides some basis from which men can
then, with the consultation of their doctors, carefully weigh other
risk factors and the full range of options available to them. Do they
have a family history of prostate cancer? Are they more advanced in
age? Has their PSA level increased sharply over time? That's the
nature of thorough, cautious, preventive medicine - and just what the
doctor should order.

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