PSA Screening Test for Prostate Cancer:
An Interview with Otis Brawley, MD
By Maryann Napoli
The prostate-specific antigen (PSA) screening test for early prostate cancer has been surrounded by controversy ever since it was introduced over 15 years ago. The test can indicate the presence of cancer, but many men have a form of prostate cancer that will remain dormant or is so slow-growing that it will never cause symptoms. Neither this test, nor any other can distinguish which prostate cancer will become lethal. Furthermore, there is no proof that the use of the PSA blood test to screen symptom-free men will spare anyone a prostate cancer death, yet it is associated with a considerable amount of unnecessary treatment with aftereffects that can be both severe and permanent. All of the treatments for early prostate cancer carry the risk of impotence and incontinence. In short, cancer researchers do not know whether PSA screening saves more lives than it ruins.
Otis W. Brawley, MD, is the brains behind the ongoing National Cancer Institute Prostate Cancer Prevention Trial, which is designed to answer questions about the effectiveness of screening and the causes of prostate cancer. After leaving the National Cancer Institute, Dr. Brawley became the Director of the Georgia Cancer Center and Professor of Medicine, Oncology, and Epidemiology at Emory University School of Medicine. He is interviewed about the ever-increasing use of PSA screening in the face of so much uncertainty about its value.
Napoli: Does the popularity of PSA screening concern you?
Dr. Brawley: First of all, I'm not against prostate cancer screening. I'm against telling people that it is well established; and that it works; and that it saves lives when the evidence that supports those statements simply does not exist. I'm a tremendous supporter of the real American Cancer Society (ACS) recommendation, which is: Within the physician-patient relationship, men should be offered PSA screening and should be informed of the potential risks, as well as the potential benefits and be allowed to make a choice.
Napoli: Do you think fully informing men about PSA screening happens very often?
Dr. Brawley: I think it rarely happens. Many doctors are uninformed, and that's a big problem. My great concern is people being misled. I routinely follow the prostate cancer screening recommendations of 18 organizations in the U.S., Canada, and Western Europe. The two most pro-screening recommendations are those of the ACS and the American Urologic Association. Both of whom say it should be offered to men; men should be informed of the potential risks and the potential benefits; and they be allowed to make a choice. The ACS does not recommend that men of normal risk be offered mass screening. There's a distinction between what is done within a doctor/patient relationship at a doctor's office and mass screening.
Napoli: What is the difference?
Dr. Brawley: Mass screening takes place at a booth at a mall where screening is offered to anyone who comes by and wants screening. In the last few years, there has been screening on the floor of the Republican National Convention, health fairs at the mall, [TV] channel this or channel that will have a health fair with prostate cancer screening. Yet there is no organization that endorses mass screening because of the concern that you can't have informed consent.
Napoli: If policy makers aren't promoting the test, who is?
Dr. Brawley: The British Medical Journal recently published an article about how several of the leading prostate cancer survivor organizations [based in the U.S.] that do a lot of the pushing of screening are funded by the makers of the PSA screening kits. And, indeed, [these survivor organizations] do things that the Food and Drug Administration won't let the manufacturers do--like make promises that there are only benefits from prostate cancer screening. Many of these prostate survivor organizations that I'm critical of--that take drug company money--offer mass screening.
Napoli: You were once quoted in The New York Times saying that 30-40% of men whose cancers appear to have been confined to the prostate at diagnosis will recur soon after treatment.
Dr. Brawley: Yes, this [brings up] one of the lies perpetrated about prostate cancer. If you look at the prostate cancer outcomes from a huge study conducted by the National Cancer Institute, close to 40% of men who undergo a radical prostatectomy will have a PSA relapse within two years. This means that they had disease that was outside of the prostate that was not obvious to the surgeon or the pathologist. It means that if the man lives long enough, metastatic disease will kill him.
Napoli: The public is always told that early detection is lifesaving. How true do you think that is for prostate cancer?
Dr. Brawley: If you have a group of men diagnosed as a result of PSA screening, 30-40% don't need to know that they have prostate cancer because it's meaningless in terms of risk to their health. And for somewhere between 30% and 40% of the men with prostate cancer, no matter what [treatment is given], the disease is not curable. And then maybe there are about 20% who actually benefit.
Napoli: And there's no way to know which type of prostate cancer you have.
Dr. Brawley: That's right.
Napoli: What about African American men, who as a group, are at a particularly high risk for prostate cancer? PSA testing is thought to be advisable for them at an earlier age.
Dr. Brawley: The proportion of black men in Rocky Feuer's paper [for the Journal of the National Cancer Institute] who don't need to know they have prostate cancer was over 40%, compared to 30% of white guys. The reason it's higher for black men is that they have so many other competing causes of death. The other issue is this: It's a principle of cancer screening that, unfortunately, many of the advocates of screening just don't comprehend, and that is, the more aggressive cancers are less likely to benefit from screening. There are people out there who say we must screen black men because they have more aggressive prostate cancer. [These screening proponents] do not realize that they are saying, in effect, because prostate cancer screening is less likely to benefit black men, then we must screen black men.
Napoli: You recently published a medical journal article about informed consent and the PSA test.
Dr. Brawley: Yes, the problem I have is that people are not open and honest about all the controversies, and this extends to people being not open and honest about the treatments, once prostate cancer is diagnosed. Men tend to get railroaded toward radical prostatectomy or to external-beam radiation, or to seed implants.
Napoli: Since there's no evidence that any one of these treatments is superior to another or superior to no treatment, for that matter, where do you suggest men go for unbiased information?
Dr. Brawley: First of all, I think we should tell men what is scientifically known and what is scientifically not known and what is believed and label them accordingly. [As for credible sources of information,] the National Cancer Institute's PDQ treatment statements at www.cancer.gov are good [call 800/4-CANCER]. So is the ACS's information. And by the way, we at Emory have figured out that if we screen 1,000 men at the North Lake Mall this coming Saturday, we could bill Medicare and insurance companies for $4.9 million in health care costs [for biopsies, tests, prostatectomies, etc]. But the real money comes later--from the medical care the wife will get in the next three years because Emory cares about her man, and from the money we get when he comes to Emory's emergency room when he gets chest pain because we screened him three years ago.
Napoli: You're saying that screening creates long-term customers. So, did Emory Healthcare decide to go ahead with the free PSA screening on Saturday?
Dr. Brawley: No, we don't screen any more at Emory, once I became head of Cancer Control. It bothered me, though, that my P.R. and money people could tell me how much money we would make off screening, but nobody could tell me if we could save one life. As a matter of fact, we could have estimated how many men we would render impotent...but we didn't. It's a huge ethical issue.