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October 7, 2011
Panel’s Advice on Prostate Test Sets Up Battle
By GARDINER HARRIS
A day after a government panel said that healthy men should no longer get screened for prostate cancer, some doctors’ groups and cancer patients’ advocates began a campaign to convince the nation that the advice was misguided.
Their hope is to copy the success of women’s groups that successfully persuaded much of the country two years ago that it was a mistake for the same panel, the United States Preventive Services Task Force, to recommend against routine mammograms for women in their 40s. This time, the task force found that a P.S.A. blood test to screen for prostate cancer does not save lives, but results in needless medical procedures that have left tens of thousands of men impotent, incontinent or both.
Both sides in the battle have marshaled distinct arguments, and both said their only goal was to protect patients. Caught in the middle are 44 million men in the United States over the age of 50 who must now decide whom to believe. Some have already had a P.S.A. — prostate-specific antigen — test and must choose what to do with the result. Others have undergone biopsies, surgeries, radiation therapy and even drug treatment that results in a form of chemical castration. Many have suddenly confronted the thought, perhaps for the first time, that their pain and suffering may have been for nothing.
Members of the government panel said they knew that they would have to defend their recommendation and delayed issuing their report for two years to prepare for the battle that was certain to ensue. Dr. Michael L. LeFevre, co-vice chairman of the task force, said the panel originally voted against routine screening for prostate cancer in 2009. But after the firestorm over its advice on mammography, Dr. LeFevre said he deliberately slowed down the process.
“I looked at this and said, ‘I know this is going to happen with prostate cancer for all the same reasons, and we absolutely have to have the science right,’ ” he said. As for the resulting delay, Dr. LeFevre said, “I will take full blame and full credit.”
If the panel’s analysis of the science is correct, thousands of men were probably harmed by unnecessary tests and treatments during the delay.
At the heart of its advice is the startling finding that thousands of doctors in the United States have been doing many of their patients more harm than good. While the panel did not explicitly level such a charge, Dr. LeFevre said that the dangers of common treatments were what drove the members to recommend against screening. “If you’re the guy doing the treatment, that’s pretty hard to swallow,” he said.
Sure enough, urologists — the doctors who most often treat prostate cancer — promised to fight. The American Urological Association issued a statement saying that the recommendation “will ultimately do more harm than good.” Many urologists reacted angrily.
“All of us take extraordinary issue with both the methodology and conclusion of that report,” said Dr. Deepak Kapoor, chairman and chief executive of Integrated Medical Professionals, a group that includes the nation’s largest urology practice. “We will not allow patients to die, which is what will happen if this recommendation is accepted.” He and other urologists said that the P.S.A. test is just one part of an overall strategy that, in the hands of well-trained doctors, can help prevent death and other consequences of cancer.
Treating patients with prostate cancer is a highly profitable business in the United States, and much of the practice of urology is dedicated to this fight. If men no longer get screened routinely, urologists will see a steep decline in patient visits and income. But Dr. Kapoor rejected the notion that profit plays any role in his defense of screening.
“That I’m going to treat patients that don’t need therapy is morally repugnant,” he said.
But Dr. Otis Brawley, chief medical officer of the American Cancer Society, suggested that is what doctors like Dr. Kapoor are doing. “We in medicine need to look into our soul and we need to learn the truth,” he said. “If your income is dependent on you not understanding something, it is very easy not to understand something.”
Dr. Derek Raghavan, president of the Levine Cancer Institute in Charlotte, N.C., said that at the very least, men must stop being so anxious about the results of their P.S.A. tests. “Men come into my office crazy and absolutely fearful,” he said. But even P.S.A. test results that are considered high by many doctors — in the hundreds, for instance — are not dangerous unless the levels are rising rapidly, Dr. Raghavan said.
“We need to educate men to slow down,” he said.
But Dr. J. Brantley Thrasher, chairman of urology at the University of Kansas Medical Center, said he feared that the task force’s recommendation will eventually lead insurers to stop paying for many prostate cancer treatments and lead many men not to get tested.
“There is no question that some people are being overtreated in this country,” Dr. Thrasher said. “But we can’t go back to the day when men waited so long to be treated that all I could do for them was give them narcotics and wait for them to die.”
The choices are fateful for men, many of whom believe the P.S.A. test saved their lives. Robert Ginyard, 49, of Baltimore, said he had gradually rising P.S.A. tests for years when his doctor finally suggested he see a urologist. A biopsy showed that he had cancer, but not an aggressive kind.
Studies show that many men have cancer in their prostate that never results in illness or death. But Mr. Ginyard, like many men, could not live with the idea that he was harboring cancerous cells. His father had prostate cancer, and he is black — factors that put him at higher risk. But he is in his 40s, and dangerous prostate cancer is very rare in men younger than 50.
“I’ve got two young daughters, and that man instinct kicked in,” he said. “And I said, ‘It’s not about my life right now. It’s about making sure that I take care of my family.’ If you have cancer, you get it out and you bother with the statistics later.”
So Mr. Ginyard had his prostate removed last year and underwent radiation therapy. The side effects, including impotence and incontinence, were significant, but he said they have since passed.
The task force’s recommendation, he said, “gives men another reason to place their personal health and well-being on the back burner.”