MIAMI — Marc Henderson, a 63-year-old African-American airport executive here, isn’t afraid to ask his physician to do a blood test for Prostate Specific Antigen (PSA), a screening test for prostate cancer.
“I’d rather know early on so that it can be treated, rather than sit around in denial until it’s too late,” he said. “If it’s going to help catch something, I have no problems with it.”
Henderson’s views aren’t unusual. For years, doctors have routinely ordered the PSA on men older than 50, along with tests for cholesterol and blood sugar. Just as the goal of screening mammograms is to prevent deaths from breast cancer, the goal of routine PSA testing is to catch prostate cancer early, when it’s easier to treat and more likely to be cured.
Prostate cancer is the second leading cause of cancer death among men in the United States, and routine PSA tests have led to the diagnosis of early prostate cancer in millions of men with no symptoms of the disease. Overall, 16 out of 100 men will be diagnosed with prostate cancer during their lifetime, and three out of 100 will die of the disease.
Prostate cancer hits black men especially hard. One out of every five black men will be diagnosed with the disease during his lifetime, and five out of 100 will die from it. Black men are more likely to be diagnosed with prostate cancer that is more aggressive and more advanced than are men of other ethnicities. They are also more likely to develop the disease at a younger age than other men.
Unfortunately, the PSA isn’t a great test. It’s often abnormal in men who don’t have cancer (and sometimes, it’s normal in men who do have cancer). Widespread testing has led to millions of men without prostate cancer undergoing biopsies, in which a needle is used to take a small piece of the prostate to examine under the microscope. Also, prostate cancer is extremely common, and most early cases don’t spread to other organs. Those that do spread often take many years to progress to the point where they are fatal. Most men with prostate cancer die of other diseases. Because of early detection, many men undergo aggressive treatment for a cancer that, left alone, would not kill them.
Because of these drawbacks, the United States Preventive Services Task Force (USPSTF), a prominent panel of doctors and health experts, recommended earlier this year that men not undergo routine screening. After reviewing several large studies of PSA testing, the panel concluded that the risks of testing – specifically, complications of biopsies and of treatment, such as infections, bleeding, urinary and sexual problems – outweigh the benefit of lives saved as a result of the test. The USPSTF reported that routine PSA testing saves one man out of 1,000 – at most – from dying of prostate cancer.
Meanwhile, out of 1,000 men who are screened, 30 to 40 will develop erectile dysfunction or problems controlling their urination, two will have a heart attack or stroke, and one will develop a potentially life-threatening blood clot as a result of treatment for prostate cancer. In all, the USPSTF reported, one out of 3,000 men screened for prostate cancer will die due to complications from surgical treatment.
The studies the USPSTF reviewed didn’t include many black men, and most were done in Europe. Nonetheless, the panel didn’t make a separate recommendation for blacks. Instead, it stated that because so few black men were in the studies, “no firm conclusions can be made about the balance of benefits and harms of PSA-based screening in this population,” and described PSA screening based on race as “problematic … in the absence of data.”
The panel’s report also cited a recent large U.S. study that did include a large number of black men with early prostate cancer and found no difference in survival at 12 years between those who underwent aggressive prostate surgery, versus those who were closely monitored, but didn’t receive prostate cancer treatment. The leading black physicians’ organization, the National Medical Association (NMA), vehemently disagreed with the USPSTF’s recommendation.
“It just doesn’t make sense,” said Dr. Cedric Bright, a general internist who is an associate professor of medicine at the University of North Carolina – Chapel Hill and a former NMA president. “I’ve seen enough prostate cancer that started early and was more aggressive.” He added that the panel’s conclusions “may be more generalizable to those who are of European background. There are very few African-Americans in the studies.”
In a statement issued in response to the USPSTF recommendation, the NMA describes PSA screening as “the best method to detect early stage, curable prostate cancers.” The NMA supports the American Urologic Association’s screening guidelines, which include beginning PSA screening at age 40, including a doctor’s office rectal exam as part of the screening, assessing a man’s risk based on his age, ethnicity, family history, and aspects of his PSA result, such as how much it has increased over the past year and whether it is high compared to the size of his prostate. It also encourages men to engage in a discussion of risks and benefits with their physicians, and advocates educating people in the community about prostate cancer and making health care easier to obtain.
The NMA statement cites a 2010 autopsy study of more than 1,000 black and white men in Detroit suggesting that prostate cancer grows more rapidly in black men and/or changes from an indolent to an aggressive form sooner in blacks.
Bright believes there’s a need for more research to study PSA screening’s effectiveness among black men. In the meantime, however, he is worried that insurance companies will respond to the USPSTF’s recommendations by deciding not to cover PSA screening. He says he has already begun to see a “backlash” of men deciding not to be screened.
And while Marc Henderson is aware of the USPSTF’s recommendation, he says it doesn’t affect his decision to get the PSA. “Yes, statistics may be good for the population, but everything in life is individual,” he said. “African-American males need to be cognizant of their health.”
Dr. Erin Marcus is a general internal medicine physician and writer based in Miami.
April 18, 2014 //
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