An oncologist's opinion on prostate screening

Last week the U.S. Preventive Services Task Force - a panel of independent experts - found that healthy men need no longer undergo PSA screens for prostate cancer because the tests don't save lives and lead to harm from unnecessary care. Curtis Miyamoto, chair of radiation oncology at Temple University Hospital, discussed the issues with Trishula Patel.

Question: What is the PSA test, and what do you think of the new recommendations?

Miyamoto: PSA, which stands for prostate-specific antigen, is actually found normally in men's bodies. It's an enzyme made by the prostate gland and its normal function is to break up fluids so sperm can swim free. PSA can range in a normal man from 0.1 to 4. I qualify that because in African American men, we'd bring that down to 2.5.

PSA comes in two forms - free form and bound form. In a normal man, the free form should be 23 percent or higher. PSA does go up with age, so the older you get, the higher the PSA can be.

The crux of the matter is that the new screening recommendations are not to screen. That to me is excessive, and part of the reason I say this is because in the U.S. alone, there will be almost 25,000 more cases diagnosed this year than last year. The incidence is increasing, and the result will be more than 33,000 deaths this year.

Prostate cancer is not one disease - it comes in a range of stages and aggressiveness. And it's wrong to make the blanket statement that men should not be screened knowing that more than 33,000 will die from it this year.

I admit there are excessive screenings for men who will never actually benefit from it, but you cannot make the broad statement that we're not going to do this anymore. And just because the studies are conflicting doesn't mean we should not do it.

You have to look at things on an individual basis. Look at family history, even if you may be healthy. The American Cancer Society has guidelines, and their recommendation of screening at age 50 is a reasonable one. . . . The task force that came up with these new recommendations is not made up of oncologists, so I don't know that they can make recommendations on cancer. What we're doing does make a difference, and treatments are not as morbid as they used to be.

Q: While the test can detect the presence of cancer, it's hard to know if it's really deadly prostate cancer or the harmless kind. The resulting care can be unnecessary and harmful. Your thoughts?

A: Part of what people are confused about is related to the two types of PSA. Determining the amount of "free PSA" in the total PSA can help tell whether the cancer is malignant or not. You can watch PSA over multiple tests to see if it goes up, but it's all age-dependent and overall health has to be taken into account.

Q: What about the unnecessary treatments and the harm that can result?

A: Again, education and selection are very important. It's ultimately up to the physicians. Like anything else, there are abuses. Good judgment is what's needed here. There are also the legal aspects to consider: If you don't treat someone in a timely fashion and they die, you could get into trouble.

Q: What's your best advice for healthy males?

A: They should discuss it with their physician and know the risk factors, and try and minimize the risks - especially if it runs in the family and at an early age from genetic factors. If they're at risk, there are screenings that are done free at many locations, and primary-care physicians can order them for men under age 70. For men over 70, I'd say look at the risks and benefits and realize that if they're not in that good health, not everyone needs to be treated. . . . At the same time, I feel bad when I see patients whose doctors recommended not getting screened and then end up having to come see me when they're dying.

Q: How does a family history or being in a certain ethnic group change things?

A: African Americans have the highest risk - period. That group definitely needs to be screened. And Caucasians are at a higher risk than Asians and Hispanics. As far as family history goes, it is very important, especially when you look at age. If any first-degree relative has prostate cancer, you should be screened, even if you're otherwise healthy.

Q: What is the PSA number that requires action?

A: There is debate here, especially when deciding if African Americans especialy should be biopsied at 2.5 or not. In an average person, say if my PSA was between 4 and 10 and I was 60, you might want to look at free PSA to see if that's a good or bad ratio. And then potentially if you're healthy, get a biopsy.

Q: Men who already have prostate cancer should keep getting the test, right?

A: Yes, absolutely.

Q: Do you get the test?

A: Yes, because I'm over age 50.