Your Best Friend May Be Another’s Killer: The PSA Problem

What do you do when the inventor denounces his own product as a disaster? Most customers would stop buying it, stores would remove it from shelves and some would sue the manufacturer for the harm it has caused.

But this isn’t what has happened with the P.S.A. test, the blood screening procedure to detect prostate cancer. Although Richard Albin, the doctor who developed the test, calls its widespread use a “public health disaster,” many doctors and prostate cancer patients are incensed that the United States Preventive Services Task Force, after an exhaustive review of the literature, now encourages men to forego the screening, claiming that it causes more harm than good.

Newt Gingrich, in a Republican primary presidential primary, said that the task force proposal would lead to more deaths. A few days after the task force released its new recommendations, Rudy Giuliani and baseball’s Joe Torre, both of whom were treated for prostate cancer after it was discovered by the P.S.A., presented themselves as examples of the importance of routine testing. Without it, they say, they would never have detected the cancer in its early stages. The test saved their lives, they say.

As far back as 2002, the two New Yorkers touted the advantages of the test. Giuliani and Torre learned they had the disease early on because of routine tests.

“It’s a simple test, it doesn’t hurt, and if you keep doing it on a regular basis every year, then you have a baseline, and if prostate cancer emerges, you’re going to know you treated it as soon as possible,” Giuliani said.

But the evidence says otherwise. So why continue to tout the test when the evidence is pointing in the other direction?

One answer is cynical: follow-up procedures for positive test results are big business. Those whose livelihoods are tied in with the treating prostate cancer are reluctant to give up a lucrative deal. Some patients defer to their physicians, finding it too difficult to sort through the information themselves, an understandable reaction to a highly anxiety-producing situation.

There is a less cynical answer, one hinted at by Torre in 2002 when he called the test “your best friend.”

Best friends aren’t tossed aside, especially if you believe they saved your life. There is a bias in their favor; they are given the benefit of the doubt. And, in fact, they may have saved your life. The problem is that this savior of yours may not be so kind to others. In regards to the P.S.A., the facts are, as reported in the NY Times, “one million men received surgery, radiation therapy or both who would otherwise not have been treated without a P.S.A. test. . . Among them at least 5,000 died soon after surgery and 10,000 to 70,000 suffered impotence, incontinence or both.”

Put another way, for every 48 prostate surgeries performed, one patient benefits, and the other 47 would have lived just as long without the surgery. This adds up to a patient being “24 times as likely to experience the side effect than the cure.”

Torre’s best friend is more like an assailant for most men. This is why Richard Albin called the P.S.A. a public health disaster. Not for those whose operations were successful, but all the others who suffered from, at the least of it, anxiety, all the way to dying because of biopsies gone wrong and life-long, debilitating side-effects from surgery that may have been unnecessary in the first place.

It is easy to understand the bias that urologists have towards continuing the testing. And it isn’t too difficult to understand why those who have undergone procedures as a result of the P.S.A. remain committed to routine testing. Few readily admit to making mistakes. There is a great need to justify our actions and decisions, all the more so when it is the word of a trusted physician against that of a faceless statistician. As Carol Tavris and Elliot Aronson write in Mistakes Were Made (but not by me), “our efforts at self-justification are all designed to serve our need to feel good about what we have done, what we believe, and who we are.”

In order to maintain a self-image as a smart, competent person, many will continue to justify the correctness of past decisions despite the evidence to the contrary.

This isn’t to say that the P.S.A. is worthless or that it should be abandoned. It provides some information and sometimes it is useful. But what the information means and what it means to any particular man is a matter of judgment. Each man needs to decide for himself how much risk he is willing to live with and the extent to which he favors medical intervention over letting nature take its course.

In other words, the use of the P.S.A. is as much a psychological matter as it is a scientific one.


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