Without PSA, Prostate Cancer is a Silent Disease

BY MARK SCHOLZ, MD

Prostate cancer in the male population is like a vast subterranean reservoir of oil.  Unless you sink a well, you don’t know it’s down there.  The confusing thing is that prostate cancer rarely causes symptoms, even when the disease is advanced.

My career was just beginning when PSA testing first become popular in the early 1990s. Even back then the test was controversial, but for a different reason than today: No one could believe that a simple blood test detects cancer.

The medical practice I have today grew quickly because we embraced PSA testing early on when many other doctors were still skeptical. Our practice grew - patients self-referring themselves after having a shocking experience with their other doctor. Too often back then, worried men’s concerns were dismissed by their doctors in conversations that went like this:

“Hey doc, what about this new blood test called PSA?  I hear it helps detect prostate cancer.” 

 “PSA? You can forget that.  No blood test shows cancer.  You can’t trust it.  You are perfectly fine. You don’t have any urinary problems whatsoever.”

 

“But doc, I read about it in the paper.  It’s really supposed to work.”

“I can’t believe you are trying to tell me my job!  Do you think you can come in here and teach   me something by reading out of some damn column in the Los Angeles Times?   Trust me.  These new tests are unreliable.”

 “Aw come on doc, I don’t mean to make you angry.  It only costs thirty bucks.  And really, if we don’t do it my wife will be upset.  She’s afraid because my dad died of prostate cancer. I know you don’t believe in it but can we do it anyway?   I just want to humor her.”

So the doctor capitulates and sends the PSA test off to the lab.  A few days later he is dumbfounded when the report reads 467.  No, that is not a misprint four hundred and sixty-seven.   Totally humiliated, the doctor calls the patient and properly orders a bone scan.  When the scan confirms wide spread bone metastases, the patient, having lost all confidence in his doctor for not suggesting a PSA in the first place, fires him and starts asking around to find a doctor who embraces new technology.

Experiences like these quickly burned the need for PSA screening into doctor’s psyches.  Prior to FDA approval of PSA in 1987, 90,000 men a year were being diagnosed with prostate cancer.  In 1992, when PSA screening finally caught on, almost 400,000 men were diagnosed.  After the screening process unveiled the huge backlog of men who were walking around with silent advanced disease, the rate of new men being diagnosed settled down to a mere 200,000 a year, the rate that has been maintained to the present time.

No one with half a brain believes it is sensible to stop PSA testing.  Thankfully, due to almost universal PSA testing relatively few men are being diagnosed with advanced disease any more. However, the U.S. Preventative Services Task Force appropriately believes that the pendulum has swung way too far in the other direction. Thousands of men are getting unnecessary radical treatment for early-stage disease that is totally non-threatening.   We have pursued prostate cancer so vigorously with over aggressive biopsy tactics that many men are being diagnosed with an inconsequential disease Ralph and I christened, “The Uncancer.”

In my last blog, I promised to outline the pathway out of this conundrum, of throwing the baby out with the bathwater by nixing PSA testing altogether.  IHowever, in today’s blog I decided to postpone the fulfillment of that promise until my next blog.  I felt we first needed to be reminded  how the prostate cancer world looked at a time before PSA testing was widely adopted.