A PSA On PSAs
In the world of broadcast, “PSA” means “public service announcement.” In the world of cancer treatment, it means the screening test that men get in order to evaluate their risk of prostate cancer.
Yesterday two big studies were released on whether PSA screening produces more good or more harm. The reporting on the studies –examples are found in the New York Times, the Washington Post, USA Today and the Wall Street Journal— made a hash of the results, and could actually lead to men not getting screened which could lead to their early deaths from cancer.
“My greatest concern is that if we don’t handle this thing appropriately, we can hurt a bunch of people,” The American Cancer Society’s Otis Brawley told USA Today. “There is a group of men who should be getting PSA and who might not because of what they hear.”
That is the key message that Dr. Kenneth Tokita of the Cancer Center of Irvine told me on air yesterday. (The transcript of his interview is here.) PSA testing does indeed lead to diagnosis of aggressive cancers and to treatment that saves lives, Dr. Tokita assured my audience. But lousy reporting of the complicated results from the studies could easily influence men away from having the test or serious evaluation of the results. The New York Times’ piece seems the most irresponsible, headlinged as it is “Prostate Test Found To Save Few Lives,” and with the opening paragraph:
An e-mail arrived last night from Dr. Bruce Malkowicz, who is the Co-Director of Urologic Oncology at the University of Pennsylvania, and the Thomas D. Stichter Memorial Professor of Urologic Research for the University of Pennsylvania Health System. It provides the sort of analysis of the studies that the New York Times ought to have provided:
I am a professor of Urology and was listening to your show when I was alerted to the NYT post on the NEJM studies which were released today. A quick download of these and the editorial were quite interesting and I think it was great that you decided to discuss this issue today. I could not listen to your guest interview because I was called away to help with some clinical situation. The issue of screening for prostate cancer [CaP] is an important and controversial topic. What I was struck by in scanning the articles and what was confirmed in the editorial is the fact that while these are large trials, the reports are INTERIM ANALYSIS and not the final results of these studies. What is confirmed by the current data is our sense that prostate cancer is an over treated entity. It does not affirm or reject the role for screening. The European study actually suggests that the death rate from CaP may be reduced by 20% with the use of screening strategies although the statistical validity for this is marginal. Since this question is not answered there is definitely a role for active disease detection as part of overall male health. The key issue at this time is make a well informed decision on whether to pursue aggressive therapy or active observation. Although one can not separate the all the aggressive lesions from the slower growing lesions, general parameters exist to help categorize this to some degree. The data from these reports suggest that low risk patients can feel more comfortable in following an ACTIVE, scheduled program of follow up instead of rushing to more aggressive treatments and their side effects. Those patients with intermediate and higher risk tumors would be taking their chances. Total ignorance of the situation is not appropriate. It is true that some people can be made chronic patients with elevated PSA values that are false negatives and we have tried to deal with this by telling patients the basic statistics associated with PSA determinations. The prudent choice based on the available evidence is to first choose if you want to be ignorant of the entire situation or not, realizing that a positive lab test will probably lead to a biopsy and not testing may miss a curable cancer. Once biopsied and diagnosed, an effort needs to be made by the patient and potentially treating physicians to choose observation or therapy based on the available data and the patient’s preferences.
Medical studies are enormously complicated and difficult for journalists to translate for the public.
But if you are going to try and provide that translation, at least do a decent enough job to assure that you don’t send a false message to the public that there is no down-side to skipping screening. Experts like Dr. Tokita and Dr. Malkowicz are pretty easy to find and to quote at length in order to get the story right. The screen you skip on the advice of some sloppy journalist could be the one that could have saved your life.