> June 20, 2005
> P.S.A. Test No Longer Gives Clear Answers
> By GINA KOLATA
> LAST November, Rabbi Samuel M. Stahl was worried that he might have prostate
> cancer. He had had two P.S.A. tests in the past six months. Both times, his
> levels were well within the range that had been considered normal, but the
> second level was higher than the first.
> His internist told him to relax. The blood test looks for a protein, the
> prostate specific antigen, which can signal cancer. Only test results higher
> than 4 were worth worrying about, the doctor contended, and both tests were
> below that.
> But Rabbi Stahl, who lives in San Antonio, remembered advice he had gotten
> from a stranger three years ago that suddenly felt eerily prescient.
> The rabbi was walking out of the city's Ecumenical Center for Religion and
> Health when he passed a man who was walking in.
> "The man said, 'Are you here for the prostate cancer support group?' " Rabbi
> Stahl recalled. "I said no. Then he said: 'I just want to give you a bit of
> advice. Don't pay attention to the absolute P.S.A. number, but if you see it
> rising, that's a cause for concern.' "
> Rabbi Stahl's first P.S.A. was 2.4. But the second one was 3.4. He had to find
> out: was that jump ominous or inconsequential?
> Rabbi Stahl had stumbled into one of the great issues in medicine today. No
> longer is the P.S.A. test a simple screen with a sharp cutoff at 4. Now,
> prostate cancer experts say, all bets are off.
> The P.S.A. test "is just not as discriminating as we thought it was," said Dr.
> Michael J. Barry, a professor of medicine at Harvard Medical School.
> As a result, many experts are suggesting that the P.S.A. not be the single
> focus of prostate cancer screening, but rather one piece in a puzzle with
> other risk factors. Some experts are also asking doctors to be more open to
> the idea that some men may be better off forgoing treatment and instead be
> monitored regularly for changes in their tumor's growth. The muddied story
> emerged in a sequence of medical papers over the last year.
> First Dr. Ian M. Thompson Jr., chief of urology at the University of Texas
> Health Science Center at San Antonio, published a paper in The New England
> Journal of Medicine reporting that biopsies found prostate cancer in as many
> as 15 percent of men with P.S.A. levels below 4.
> Then Dr. Thomas Stamey, professor of urology at Stanford University School of
> Medicine, published a paper in The Journal of Urology saying that P.S.A. tests
> were virtually useless. In most men, P.S.A. levels of 2 to 10 are caused by
> nothing more than a harmless enlargement of the prostate that occurs when men
> age. But prostate cancer is so common that biopsies find prostate cancer in
> most middle-aged and older men if doctors look hard enough. So the results
> would be the same if doctors simply biopsied men age 50 and older than if they
> did a P.S.A. test first.
> And last month, Dr. Peter C. Albertsen of the University of Connecticut Health
> Center published a study in The Journal of the American Medical Association
> saying men with prostate cancers that do not look particularly aggressive
> under a microscope - the majority of men whose cancers are found with P.S.A.
> tests these days - can do perfectly well with no treatment for at least 20
> years. All they need is to be monitored by a doctor to ensure that their
> P.S.A. levels are not shooting up.
> On the other hand, a Swedish study published last month in The New England
> Journal of Medicine lumping men with more as well as less aggressive cancers
> found that those who had their prostates removed had a lower risk of death and
> of metastatic cancers than those who did nothing. But these men generally
> started out with larger tumors than the ones that are now being found with
> P.S.A.'s.
> So what is a man to do?
> The problem, said Dr. Timothy Wilt, a professor of medicine at the Minneapolis
> V.A. Medical Center, is that most men eventually develop prostate cancer, but
> most of the time it grows so slowly that it never causes problems and
> eventually they die of something else, never knowing they had cancer. Unless,
> of course, a doctor starts biopsying their prostate. With annual P.S.A. tests,
> sooner or later many men will end up with a biopsy.
> "And as we repeatedly biopsy men, we are likely to find these subclinical
> prostate cancers," Dr. Wilt said. "There is no doubt that we will label more
> people as abnormal," telling them they have cancer and throwing them into a
> terrifying whirl of decision making. Despite the arguments in the academic
> medical community about what the test means, most men are still having it
> done. But now they have to address these questions: When should a low P.S.A.
> level lead to a biopsy, and when should a tiny tumor be treated?
> There is no easy answer, Dr. Thompson said. In deciding whether to do a
> biopsy, doctors must weigh other factors along with the P.S.A. Did the
> patient's father die of prostate cancer? Is he fat? (Fat men tend to have
> lower P.S.A. levels than thinner men, so a low level in a fat man might be
> more ominous.) Is he African-American? (Blacks tend to develop more aggressive
> prostate cancers and at younger ages.) Are his P.S.A. levels steadily rising
> with no apparent cause, like an enlarged prostate or an infection, both of
> which cause elevations in the P.S.A.? Or does he have an enlarged prostate, no
> family history and a previous biopsy that found no cancer?
> "You can't condense it to a sound bite," Dr. Thompson said.
> But many doctors, he added, are either unaware of the new views on P.S.A. or
> are ignoring them.
> "I was presenting some of the data recently to a gentleman over 50 who was
> visiting our institution," Dr. Thompson said. "He looked at me with kind of
> wide eyes and said, 'Do people know this?' " The answer, Dr. Thompson said, is
> that it appears that most general practitioners do not know it. "They don't
> know that there is no such thing as a normal P.S.A. level."
> Dr. Wilt has another concern. Most patients, he said, are not being counseled
> that even if they have prostate cancer, they may not need treatment. Only a
> small percentage of prostate cancers are dangerous, and older men, in
> particular, with small tumors may be better off monitored instead of treated.
> Dr. Wilt is directing a study that should help settle the question of whether
> treatment with surgery helps save lives in men whose prostate cancer is
> detected by P.S.A. screening, but its results will not be in until 2010.
> Often the decision about what to do is thrust upon men who underwent a P.S.A.
> test without knowing it; their doctor just ordered it as part of a routine
> physical exam. Then the results came in and the doctor said the dreaded word,
> cancer.
> That is what happened to Michael Karp, a 78-year-old retired pharmacist who
> lives in Faribault, Minn.
> Back in November 1994, he said, his doctor told him he had had a P.S.A. test
> and his level was high. He was astonished. He had no idea he'd been tested. "I
> didn't even know what a P.S.A. was," Mr. Karp said.
> A biopsy was done, but no cancer was found. His P.S.A., 7.2, was presumably
> from a urinary tract infection.
> But, Mr. Karp said, his doctor insisted on yearly tests, and Mr. Karp, having
> experienced a cancer scare, did not dare refuse. The doctors, with their talk
> about P.S.A.'s and cancer, had made an indelible impression. "They've got you
> worried, they're in your head," he said.
> Then, a few years ago, his P.S.A. rose to 11.4 and a biopsy uncovered cancer.
> "I was all shook," Mr. Karp said. Should he have his prostate removed or
> destroyed, risking impotence or incontinence?
> "I went to Dr. Wilt," he said, who gave him another option.
> "He says to me: 'If you were in Sweden, you know what would happen? Nothing,'
> " Mr. Karp said. "It kind of woke me up." His P.S.A. level has continued to
> rise, but he is happy with his decision to have regular monitoring and no
> treatment. "I'm doing fine," he said.
> As for Rabbi Stahl, at age 65, he had hoped for many more healthy years ahead
> and did not want to ignore his rising P.S.A. At his insistence, his internist
> reluctantly referred him to a urologist who did a biopsy, finding a small
> cancer but one with cells showing the kind of deranged structure associated
> with an aggressive cancer.
> On Feb. 28, the rabbi had his prostate removed.
> He said his internist defended his decision to ignore those low P.S.A. levels,
> telling him he had no regrets. "He said he'd do it again the same way," Rabbi
> Stahl said. So he changed doctors.
> And, he said, he will always be grateful to the stranger who gave him the
> unsolicited advice. "If I had not run into that man, I would have done
> nothing," Rabbi Stahl said. "It was a message from God."
>
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