A man's right to know

[Brent]

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
http://www.sptimes.com/2004/05/29/Opinion/A_man_s_right_to_know.shtml

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.