According to the National Cancer Institute’s 2018 Annual Report to the Nation on the Status of Cancer, in recent years cases of prostate cancer (PCa) have up-ticked slightly after decades of steady decline. In response, the U.S. Preventive Services Task Force in May, 2018 modified its long-held recommendation against PSA screening in any men. The new advice: men 55-69 should discuss the pros and cons with their doctor and decide for themselves if screening makes sense.
So why wouldn’t it? Though the USPSTF acknowledges that PSA testing may offer potential benefit to a small number of men in this age range, they’re quick to add that many men “will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; over diagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction.”
Despite this, for legions of “worried well” guys-long-time True Believers in the “catch it early, cure it now” mantra-the USPSTF’s equivocated advice rekindles a moral quandary. If you opt not to be screened, as multiple experts still recommend, are you just being a cowardly ostrich?
“We’ve been taught to believe it’s virtuous to act in the face of risks to our health,” says biomedical ethicist, Arthur Caplan, Ph.D., of NYU’s Langone Medical Center. “But it turns out that this isn’t always the case, especially if the action you’re taking, like PSA screening, doesn’t work very well. Sometimes it’s more virtuous to do nothing.”
Alas, doing nothing can be surprisingly difficult, especially for those hoping to feel in control of their fates. Herewith some tips for making peace with your unscreened prostate.
Weigh the odds. In 2016, the most recent year complete stats are available, some 1,400,232 American men died. Slightly less than 30,000 of them died from PCa, and half of these were in their 80s or older. In other words, your odds of never dying from PCa are nearly 98 percent-and even better until very late in life.
Know the PSA test’s limitations. Even the best-case, cherry-picked outcome data suggests only a few asymptomatic men are likely to be saved by PSA screening, but the few lives saved appear to be counterbalanced by other causes of death. As 2018 meta-analysis in BMJ found, despite the small absolute benefit in PCa mortality over 10 years, PSA screening does not improve overall mortality. “You shouldn’t be moved by the illusion that the test is any good,” says Caplan, “or that the often unnecessary treatment it triggers won’t carry a huge risk of side effects.”
Put family history in perspective. “PCa is so easy to find that if you look for it, it’s there,” explains Mary McNaughton-Collins, MD, MPH, medical director of the Boston-based Informed Medical Decisions Foundation. “Because of PSA screening, we now have all these guys saying, ‘I’ve got a family history of this disease--my dad had it, my brother had it.’ But you know what? If we keep doing PSA testing, more and more men will eventually have relatives who’ve been diagnosed. And having a family history of cancer in and of itself can be nerve wracking." The Task Force, she adds, recommends against PCa screening for most men regardless of family history.
Big C, little c. Many of us still believe that cancer, unless it’s stopped early, is an implacable reaper of anyone unfortunate enough to get it. “But it turns out,” says Caplan, “that all of us, all the time, have cancer cells within us that our bodies are fighting constantly. Cancer is a minor, chronic condition that only occasionally flares into a major problem. Usually it’s not the ‘Big C’ we all fear, where you get it and whammo! you’re gone.” Much more often, it’s the ‘little c’ variety--abnormal cells changing so slowly we outlive them. “For most men,” says Caplan, “PCa is the poster child for this slow-growing form.”
Cultivate some healthy skepticism. Harvard psychiatrist Arthur Barsky, MD, has studied how different stake-holders in the “medical industrial complex” thrive on stoking our fears. “Each producer,” he wrote in an influential The New England Journal of Medicine editorial, “tries to convince the public that something is dangerously wrong, or about to go wrong, and that immediate steps must be taken to remedy the situation.” Don’t be snookered.
Be open-minded about another diagnosis. For some extremely risk-averse men, a fear of dying from PCa can be overwhelming. If this describes you, discuss your concerns with a trusted doctor. What’s really troubling you may have less to do with future PCa than current generalized anxiety disorder (GAD), a treatable condition characterized by out-of-control health, family, and/or financial fears.
Consider an alternative. If you’re still not convinced, ask your doctor about two new tests, phi and PCA3, both of which represent incremental improvements on PSA testing. Neither of these has been FDA-approved for PCa screening, and insurers are unlikely to pick up the tab. But if you’re willing to pay hundreds of dollars out-of-pocket, your doctor might agree to try one on you. Just don’t expect definitive answers, only marginally less murky ones than those provided by PSA.
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