Wristbands of every hue - signifying and supporting a host of causes
- have become must-have accessories ever since the Lance Armstrong
Foundation introduced its canary-yellow "Live Strong" bracelet in
May 2004. Last month, the National Prostate Cancer Coalition began
offering a baby blue "Do It for Dad" wristband to raise awareness of
annual prostate cancer screening tests.
The Washington-based group calls the test a "must," but that
advice is at odds with recommendations from several leading groups,
including the American Cancer Society and the U.S. Preventive
Services Task Force.
Jamie Bearse, a spokesman for the coalition, said one of the aims
of the wristband campaign is to "encourage dad to get tested." He
said that only about half of American men over 50 get screened
annually with a prostate-specific antigen (PSA) test and a digital
rectal exam.
Screening has not been shown, however, to reduce the number of
deaths from prostate cancer, which is expected to kill more than
30,000 American men this year. It will be another three years before
large studies in the United States and Europe determine whether
screening for prostate cancer saves lives.
Screening can lead to biopsies, which in turn often uncover
cancer or cancer-like cells. But most such cell clusters in the
prostate don't cause problems, either because they don't grow, or
they grow so slowly that something else causes death. Medical
science can't yet distinguish between early cancer that is likely to
be deadly and tumors unlikely to cause symptoms.
So when a biopsy reveals cancer, a patient is usually treated.
That typically means surgical removal of the prostate or irradiation
of the gland. At least half of the men who undergo either treatment
are left incontinent or impotent, says Dr. Russell P. Harris, a
professor of medicine at the University of North Carolina School of
Medicine in Chapel Hill, N.C., and a member of the U.S. Preventive
Services Task Force.
Doctors began using the PSA test as a prostate-cancer screening
tool in the late 1980s. Since then, about 1 million more men have
been diagnosed with prostate cancer than would have been if the PSA
test had not been widely used, according to Dr. H. Gilbert Welch,
co-director of the VA Outcomes Group at the VA Medical Center in
White River Junction, Vt., and author of "Should I Be Tested for
Cancer? Maybe Not and Here's Why," published last year. Most of
those additional patients probably did not need treatment, said
Welch.
Proponents of the PSA test observe that it has dramatically
improved prostate-cancer survival. Coalition spokesman Bearse said,
"Ninety-nine percent survive prostate cancer if it's detected
early." But Welch and others have observed that the striking
increase in survival five and 10 years after diagnosis is mainly the
result of diagnosing men earlier - when they are unlikely to die
whether they're treated or not - and diagnosing men who were not
going to die of prostate cancer anyway.
Prostate cancer death rates have been declining since the early
1990s. The age-adjusted mortality rate for prostate cancer dropped
28.5 percent from 1991 to 2002, according to the American Cancer
Society. Bearse said his organization attributes this to treatment
advances and a big jump in the number of men getting early
detection. Harris said screening may or may not help account for the
lowered death rate - it's not yet clear.
Just because there is a lot of uncertainty around the PSA test
doesn't mean that men shouldn't get it, said Welch. "It just means
that you should realize the deal. Does it reduce the number of
prostate cancer deaths? We don't really know that. We know that it
does diagnose people who would never need to know they have the
disease otherwise."
Current guidelines from the American Cancer Society call for
doctors to "offer" a digital rectal exam and PSA to patients
beginning at age 50, or age 45 for those at higher risk. "Health
care professionals should give men the opportunity to openly discuss
the benefits and risks of testing at annual checkups," according to
the guidelines. The U.S. Preventive Services Task Force concluded
"that the evidence is insufficient to recommend for or against
routine screening for prostate cancer using prostate specific
antigen testing or digital rectal examination."
Dr. Peter Albertsen, a professor and chief of urology at the
University of Connecticut Health Center, said that both
over-promoting the PSA and condemning the test are extreme
positions. It can be useful, he said, especially if physicians look
at a rapidly rising score over time, which tends to spell trouble.
There is a subset of men definitely helped by the PSA. But he
acknowledged that overuse of the test has resulted in
over-diagnosis.
"It's a dilemma," he said. "A lot of us have been a little bit
hesitant to go off and get blue armbands. If you don't tell people
the upside potential and the downside potential, I don't think
you're doing them a favor. This test creates almost more emotion
than science."
Ultimately, he said, he hopes that the PSA test will be replaced
by a technology that uses a DNA or protein signature to find
potentially deadly cancer so that only the men who need treatment
will get it.
