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Prostate Controversy

The Prostate Cancer Awareness Week ( has compiled the following information on the prostate testing controversy.

PSA Changes Over Time Flag Cancer Risk
Kaiser Permanente Recommends Against Prostate Screenings
The Prevalent View of ASCO, the American Cancer Society and many HMO's
The Danger in this View
Best Reason to Fight for More Research

PSA Changes Over Time Flag Cancer Risk

Changes in prostate specific antigen levels over time can offer significant clues to which patients are more likely to develop aggressive, life-threatening cancers, a new Kaiser Permanente study suggests.

Despite the recent controversy over of the use of PSA tests — the most commonly used screening method for prostate cancer today — the new findings indicate they may play an important role in helping to accurately identify men who are more likely to be at risk of death from more lethal, fast-growing tumors.

"The use of a single, elevated PSA level to screen for prostate cancer is considered controversial given the questionable benefits of PSA screening on prostate cancer mortality," said lead researcher Lauren P. Wallner, a post-doctoral research fellow at Kaiser Permanente Southern California's Department of Research & Evaluation.

“The screening may also result in unnecessary prostate biopsies and subsequent treatments for localized prostate cancer, as it does not distinguish well between slow-growing and aggressive disease. [But] our study demonstrates that repeated measurements of PSA over time could provide a more accurate — and much needed — detection strategy for aggressive forms of prostate cancer."

For the study, published in the British Journal of Urology International, Wallner and colleagues examined the electronic health records of nearly 220,000 men (ages 45 and older) who had at least one PSA measurement and no history of prostate cancer over a 10-year period.

The results showed that annual percent changes in PSA more accurately predicted the presence of aggressive prostate cancer, compared to single measurements of PSA alone, but only slightly improved the prediction of prostate cancer overall. Men in the study were found to experience a 2.9 percent change in PSA levels per year on average and that the rate of change in PSA increased modestly with age.

"The results of this study could provide clinicians with a better prostate cancer preventive strategy that could help differentiate between men with an aggressive form of the disease and those who have slow-growing, indolent cancer that may not necessarily merit treatment," said Wallner. "While we do not suggest that patients proactively seek out additional PSA measurements, men who already have had multiple PSAs may consider discussing the change in their PSA levels with their clinician when determining future treatment strategies."

The PSA test measures the level of an antigen, made by the prostate, in a man's blood. The higher the PSA level, the more likely a prostate problem is present. But many factors, such as age, race, and non-cancerous conditions can affect PSA levels.

The U.S. Preventive Services Task Force recommends against PSA screening for men who do not have symptoms. But many health experts recommend that men age 40 and older consult their doctors about the PSA test.

After non-melanoma skin cancer, prostate cancer is the most common cancer among American men. It is diagnosed in more than 215,000 men annually; 28,000 die from the disease each year.

Kaiser Permanente Recommends Against Prostate Screenings

Let Kaiser speak for themselves. Form 97282 reads: Recommendations based on the latest medical research:

* The Reasons Kaiser gives for not having a PSA test:

Many other expert organizations like the U.S. Preventive Services Task Force, the National Cancer Institute and the Canadian Task Force on Periodic Health Exams do not recommend PSA testing. Althought the American Cancer Society recomends prostate cancer screening and wants to increase public awaerness, the more frequent testing that they recommend has not been shown to prevent prostate cancer deaths. (Actually, the American Cancer Society no longer recommends testing, either.)

The Prevalant View of ASCO, the American Cancer Society and many HMO's

There is some controversy about using the PSA test as a screening test with large numbers of men with no symptoms of prostate cancer. The PSA test is useful for detecting early prostate cancer, but it has not yet proven to lower death rates. It also detects conditions that are not cancer, and misses some prostate cancers.

Unlike other cancers, prostate cancer grows very slowly in many (not all) men, so slowly that they would not threaten the life of the patient if not treated. So detecting cancer may subject some men to surgery and other treatments that might not ever be needed. Since prostate cancer treatments have significant side effects, treating it unnecessarily can seriously affect a man’s quality of life.

Until there is more complete research to evaluate, ASCO does not yet have an official statement about prostate cancer screening, or recommendations for men on when they should start getting tested for prostate cancer. Patients should discuss their situation with their doctor and work together to make a decision.


The Danger in this View

It's important to note that it is not easy to predict which tumors will behave aggressively and which will act in an indolent fashion. If you're a man over 40, you don't need another excuse to avoid taking care of your health. Unless you think it's worth gambling your life. Retired General Norman Schwarzkopf said it best when he was diagnosed with prostate cancer - "You cannot sit back and do nothing because you'll never have perfect intelligence on the enemy...Get on with it."

Prostate cancer is the most commonly diagnosed malignancy in American men. It is curable if diagnosed early. Early detection is the key.

About 30,000 men will die from it this year alone. Men over 40 don't need another excuse to avoid taking care of their health.

But the argument against the use of the prostate specific antigen blood test for detecting prostate cancer has provided that excuse -- pitting public health officials and primary care physicians, who claim there is no evidence of PSA success beyond a reasonable doubt, against many urologists who ask why a 27 percent decline in prostate cancer mortalities in the past five years isn't evidence enough.

Despite American Cancer Society and American Urological Association guidelines that encourage doctors to offer a PSA test and a digital rectal exam while discussing the risks of the disease, too many doctors lean toward discouraging the test, focusing on misplaced convictions that the test discovers insignificant tumors and that it doesn't save lives.

Physicians who have deferred or waffled on PSA testing are losing their licenses and seeing their malpractice insurance carriers pay out millions of dollars to bereaved families.

In a November 2001 wrongful death suit, a widow was awarded $3 million in a case in which the doctor in question "did not tell the patient about [the high PSA level] or recommend further testing or follow up visits."

A study at Long Beach Community Cancer Center of 48 such prostate cancer malpractice cases determined that, of the 22 awards totaling over $8.4 million, roughly $7.5 million "could have been avoided if PSA screening and diagnostic guidelines . . . had been followed."

These cases have become legal benchmarks as the PSA debate has moved from the doctor's office into the courthouse. They should come as a warning to science and public health policy officials across the country: If you continue to delay a decision on PSA, lawyers and lawmakers will make it for you.

Urologists will tell you that, despite imperfections, the PSA test has changed the prostate cancer diagnostic landscape. Before it, nearly three out of four men diagnosed with the disease were in the late stages -- when prostate cancer is neither readily treatable nor curable. The advent of screening has inverted that statistic, giving men a fighting chance. Regional studies support that early detection reduces mortality. One study in Austria shows that prostate cancer mortalities were markedly reduced with widespread PSA screening.

Even though newer blood tests help clarify the likelihood of cancer when PSA is abnormal, we still need more research to determine better models for early detection. But should we doom the thousands of men who could die waiting up to 14 years for the results of a randomized trial to determine "perfect intelligence" on the PSA? With so many lives in the balance, how much evidence do we need to convince us that prostate cancer is our enemy, not the test that so often detects it in time to permit a cure?

Men over the age of 40 -- and even younger if they are at higher risk of prostate cancer (African Americans and men with family histories of the disease) should "get on with it." Set aside the excuses and resolve to be tested every year.
Source: Carl Frankel, an advocate for the National Prostate Cancer Coalition, is retired general counsel for the United Steel Workers of America and a prostate cancer survivor.

Best Reason to Fight for More Research

The major reason all of these major organizations that deal with cancer are not recommending testing is because, unlike breast cancer, they say they haven't found anything that improves or extends a man's life if he gets prostate cancer so, basically, just let it grow.

With almost five-times more research spending per death, plus untold millions on awareness, breast cancer cures are seeing great results. At the rate men bought Viagra, you've got to believe they would spend a lot if there was something that could stop prostate cancer without becoming impotent or incontinent.

The difference is that women have raised the banners. Have spend their personal time and money to make things happen, have purchased millions of Breast Cancer Awareness Stamps, have made a difference.

Unlike women, few men have done any of those things, and while the U.S. Postal Service did create a Prostate Cancer Awareness stamp, over 50 million of the 78 million stamps went un-purchased.

Will you wake up before you get prostate cancer to find a way that helps men live out those final years happier and healthier? Will you?

Note: Spending in 1997 on research looked something like this: Breast Cancer $12,800/death, prostate cancer $2,700/death.)


Male Cancer on Increase

Prostate cancer is set to become the most common cancer in men within the next three years, experts have said. The Institute of Cancer Research said new figures show that cases of the disease have been rising steadily since 1971 and if trends continue it will overtake lung cancer before 2006. Despite this, the disease receives a fraction of the total spent on cancer research in the UK. The institute has called for more funding to help pay for research.

Men "Unwilling" to Discuss Cancer

The charity found that women are more than twice as likely as men to call its nurses for general advice about cancer. A breakdown of calls made to Cancer Research UK information nurses between 1999 and 2001 shows that men made an average of 2,531 calls each year, while 5,617 were made by women. Women were also responsible for 45 per cent of calls about prostate cancer and 40 per cent of calls about testicular cancer. Cancer Research UK's psychological oncology group, which is based at the University of Sussex, says the findings highlight a common communication problem between the sexes. Group director Professor Lesley Fallowfield said, "Feelings can be quite hard for men to discuss, particularly if it's about things like male cancers which are threatening to their masculinity and manhood. "There's also a cultural expectation that big boys don't cry' and many men do not actually ask about things that trouble them - even if it's anonymously and over a phone line. So we have to find new ways of reaching them because sharing concerns can be a real help," she added. Cancer Research UK has designated June as Men's Cancer Month and is launching a message board on its website to encourage men to discuss their experiences. Radio 5 Live sports presenter Russell Fuller, 29, who was diagnosed with testicular cancer in 1999, will be one of the first to post a message on the site. He discusses the uncertainty he experienced in the days leading up to diagnosis and urges other people to get unusual signs checked out. "Men generally don't like talking about their feelings as much and losing a testicle, like I did, can be embarrassing and almost like a loss of face," he said. "But I'm a very open person and talking about it was an invaluable help. My friends and family were very supportive, made a few jokes and did wonders for my state of mind!" The Cancer Research UK Men's Cancer Awareness Month message board can be reached at

New prostate cancer test advice overturns dogma

Men finally may be getting a clearer message about undergoing PSA screening for prostate cancer: Don't do it.

They may not listen. After all, the vast majority of men over 50 already get tested.

The idea that finding cancer early can harm instead of help is a hard one to understand. But it's at the heart of a government panel's draft recommendation that those PSA blood tests should no longer be part of routine screening for healthy men.

The U.S. Preventive Services Task Force examined all the evidence and found little if any reduction in deaths from routine PSA screening. But it did conclude that too many men are diagnosed with tumors that never would have killed them and suffer serious side effects from resulting treatment.

That recommendation isn't final — it's a draft open for public comment. But it goes a step further than several major cancer groups including the American Cancer Society, which urges that men be told the pros and cons and decide for themselves.

The new advice is sure to be hugely controversial. Already some doctors are rejecting it.

"We all agree that we've got to do a better job of figuring out who would benefit from PSA screening. But a blanket statement of just doing away with it altogether ... seems over-aggressive and irresponsible," said Dr. Scott Eggener, a prostate cancer specialist at the University of Chicago.

In the exam room, explaining the flaws in PSA testing has long been difficult.

"Men have been confused about this for a very long time, not just men patients but men doctors," said Dr. Yul Ejnes, a Cranston, R.I., internal medicine specialist who chairs the American College of Physicians' board of regents.

He turned down his own physician's offer of a PSA test after personally reviewing the research.

"There's this dogma ... that early detection saves lives. It's not necessarily true for all cancers," Ejnes said.

That's an emotional shift, as the American Cancer Society's Dr. Len Lichtenfeld voiced on his blog on Friday.

"We have invested over 20 years of belief that PSA testing works. ... And here we are all of these years later, and we don't know for sure," Lichtenfeld wrote. "We have been poked and probed, we have been operated on by doctors and robots, we have been radiated with fancy machines, we have spent literally billions of dollars. And what do we have? A mess of false hope?"

Too much PSA, or prostate-specific antigen, in the blood only sometimes signals prostate cancer is brewing. It also can mean a benign enlarged prostate or an infection. In fact, most men who undergo a biopsy for an abnormal PSA test don't turn out to have prostate cancer.

Screening often detects small tumors that will prove too slow-growing to be deadly — by one estimate, in 2 of every 5 men whose cancer is caught through a PSA test. But there's no way to tell in advance who needs treatment.

"If we had a test that could distinguish between a cancer that was going to be aggressive and a cancer that was not, that would be fabulous," said Dr. Virginia Moyer of the Baylor College of Medicine, who chairs the task force, an independent expert group that reviews medical evidence for the government.

About 1 in 6 U.S. men will be diagnosed with prostate cancer at some point in their life. Yet the cancer society notes that in Western European countries where screening isn't common, 1 in 10 men are diagnosed and the risk of death in both places is the same. In the U.S., about 217,000 men are diagnosed with prostate cancer each year, and 32,000 die.

Why not screen in case there's a mortality benefit that studies have yet to tease out? The task force outlined the problem with that:

Among the questions sure to be raised during the public comment period are how doctors should advise men with prostate cancer in the family or black men, who are at increased risk.

PSA testing also is used to examine men with prostate symptoms, and to check men who already have had prostate cancer. The new recommendation doesn't affect those uses.

Congress requires that Medicare cover PSA tests, at a cost of $41 million in 2009. Other insurers follow Medicare's lead, especially in light of conflicting recommendations.

Nor does the new recommendation mean that men who want a PSA test can't have one. If the rule is adopted — something the government will review once the task force hears comments and finalizes its guidance — it would just advise against doctors pushing it routinely.

"The truth is that like so many things in medicine, there's no one-size-fits-all," said Dr. Michael Barry of Massachusetts General Hospital who heads the Foundation for Informed Medical Decision-Making that backs ways to help patients make their own choices.

(Editor's Note: The question I have is who's going to volunteer to tell the 32,000 men who die each year not to get tested because we might have to do something that will make you incontenent.)

PSA decision guide:


Too Few Men With Low-Risk Prostate Cancers Get 'Watch and Wait' Approach

Study finds 12 percent or fewer getting active surveillance.

A wide majority of U.S. men with low-risk prostate cancer are being treated for the disease even though "active surveillance" is an option, a new report finds.

Active surveillance -- or watchful waiting -- is the careful monitoring of prostate cancer for progression of the cancer that would indicate a need for treatment. Men in the Northeast and on the West Coast were especially likely to have active surveillance rather than cancer treatment, potentially sparing them from complications associated with treatment.

The study data was collected in 2010 and 2011, and a lot has changed since that time in regard to the popularity of active surveillance, experts noted.

Active surveillance is "gaining acceptance among urologists and patients," said study co-author Dr. Hui Zhu, chief of urology at the Louis Stokes Cleveland VA Medical Center in Ohio.

"Age-appropriate men should discuss the risks and benefits of screening with their physicians, and men with newly diagnosed localized prostate cancer should ask their physicians whether active surveillance is a good option for them," he added.

There's been controversy for years about diagnosing and treating prostate cancer. Tumors considered to be low-risk may never spread, but men have often been treated anyway. But, those treatments aren't without risk. Prostate cancer treatments can cause serious and lasting side effects, such as incontinence and erectile dysfunction, according to the American Cancer Society.

In 2011, the U.S. Preventive Services Task Force discouraged the use of routine prostate cancer testing. One reason why was because of the odds that low-risk tumors would be treated. But, despite that recommendation, many doctors continue ordering the prostate-specific antigen (PSA) tests. Supporters of the test suggest that if the PSA leads to an overdiagnosis of low-risk prostate cancers, that problem can be countered with active surveillance, the study authors noted.

The new report examines a national database that includes about 70 percent of cancer cases in the country.

Of nearly 190,000 mean diagnosed with prostate cancer, between 11 percent and 40 percent would be considered low-risk enough to be eligible for watch-and-wait approach. (There isn't a consensus about which patients should consider this strategy, and the report looks at different cut-off points.) Of those men, just 7 percent to 12 percent had active surveillance, the study revealed.

Older men -- those over 60 -- were more likely to have active surveillance. Men without insurance were also more likely to have active surveillance, the study said.

The researchers found that watchful waiting was most common on the West Coast and in the Northeast. The states with the lowest levels -- under 5 percent -- were Alabama, Mississippi, Tennessee and Kentucky.

Dr. Stephen Freedland, a urologist and director of the Center for Integrated Research in Cancer and Lifestyle at Cedars-Sinai Samuel Oschin Comprehensive Cancer Institute in Los Angeles, pointed out that the report's data is outdated. The situation has "changed dramatically" over the past few years, with early research suggesting that many more men are choosing the surveillance option.

Before, he said, doctors chose treatment instead of monitoring because they weren't comfortable with watchful waiting and "didn't fully appreciate how well the patients do; how safe it is to do that."

He said it's rare for patients to simply never come back after being diagnosed.

Also, he said, "there was no imperative, no push to do it. It's a counterintuitive thing to say 'You have cancer, but I'm not going to do anything.'"

So, where does that leave men with low-risk prostate cancers?

"Prostate cancer, even the lethal form, is highly treatable when it is detected at an early stage through the use of screening," Zhu said.

"Men aged 55 to 69 years who are considering being screened for prostate cancer should have a discussion with their physicians which involves weighing the benefits of preventing death from prostate cancer against the known potential harms associated with screening and treatment," Zhu added.

The report was published online June 29, 2015 in the journal JAMA Internal Medicine.

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"You cannot sit back and do nothing because you'll never have perfect intelligence on the enemy...Get on with it." General Norman Schwarzkopf said after he was diagnosed with prostate cancer

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