Middle-aged men know the story: the PSA (prostate-specific antigen) test is an essential early-warning system for cancer. Elevated PSA levels mean cancer, which in turn means you should probably make the gutsy but necessary decision to prolong your life by having your prostate removed.
Except this story is rubbish. Says who? Says the pathologist who first observed the PSA, back in 1970.
Despite losing his own father, agonizingly, to prostate cancer at age 67, Richard J. Ablin (who is in his 70s) hasn’t had a PSA test done on himself, and doesn’t intend to. There is, he says, no reason to do so on a healthy man, he explains in his book “The Great Prostate Hoax.” Because PSA, contrary to what you’ve been told, doesn’t work as a cancer indicator.
That’s why a New England Journal of Medicine joint study of results from the US and Europe concluded, “PSA-based screening results in small or no reduction in prostate cancer-specific mortality.” Two years later the US Preventive Services Task Force declared that healthy men should not have a routine PSA test.
Look at it this way: If you had a PSA test in 2009, and it led to a biopsy, a cancer diagnosis and treatment for that cancer, there is, according to Dr. Peter Bach, a health-care policy specialist at Sloan-Kettering Cancer Center, a 1 in 50 chance that by 2019 or later, you will have been saved from dying of prostate cancer. But there is a 49 in 50 chance that you will have been treated unnecessarily.
Another approach, from cognitive psychologist Hal Arkes: Picture two auditoriums with 1,000 men in each. Auditorium One is filled with men who had PSA tests. In Auditorium Two, no one had a PSA test. Eight men in each room will die of prostate cancer.
The upside of a PSA test is small to nonexistent. But let’s not forget about the huge downside. A man who falsely believes he is about to die of prostate cancer and goes along with a surgeon’s recommendation that the gland be removed may pay a devastating price. Incontinence and impotence are bland-sounding words, but imagine your quality of life if you were forced to wear a diaper forever and could never have sex again. A radical prostatectomy robs a man of much of what made him himself. And these complications are exceedingly common: The prostate is located amid a tightly-strung nest of important nerves that is difficult to keep intact during surgery.
Ablin’s book is a gripping disaster tale about how hype, profit-chasing, hysteria and intransigence to reality reinforced one another in producing a horrendous mass medical error.
When the protein called PSA was first discovered (T. Ming Chu of the Roswell Park Cancer Institute was also involved), with higher quantities of it possibly linked to cancer, the medical community had hopes that a PSA test might turn out to be the male equivalent of a pap smear, which is a highly effective means of detecting pre-cancerous cells in the cervix.
But the PSA protein is present in every prostate, and though a reading above four (nanograms per millileter) is often called a warning sign, you could have a reading of 0.5 and have cancer, or a reading of 11 and be cancer-free.
Even if the test could reliably inform you whether you have cancer, it’d still be more or less useless. Prostate cancer is both extremely common (by the time a man is in his 40s, he already has a 40% chance of having prostate cancer, and the odds increase from there) and extremely likely to be harmless.
Think of prostate cancer as existing in two entirely different forms. It can be either a rabbit eager to burst out of its box (and into other parts of the body) or a turtle that just sits there, barely moving at all. You should worry about the rabbit, not the turtle. The PSA test won’t tell you which kind you have.
Yet a huge industry swung into action behind the PSA. One expert cited by Ablin says perhaps half of the urologists in the United States would go bankrupt without the gold rush of prostate-removal surgery that followed the PSA discovery.
Now that the worth of the PSA test has been questioned, the industry is looking for a follow-up version, but Ablin is wary of whatever replacement is found.
“When a 50-year-old man went for his yearly physical,” explains Ablin, “he routinely had a PSA test, quite often without his knowledge. The level of his PSA could propel him into the prostate cancer industry . . . the prostate gland is at the epicenter of a worldwide trillion-dollar industry and the PSA test as its kingpin. Think of PSA as oil. If the test were made irrelevant, an industry would crumble.
“You don’t have to be a conspiracy theorist to grasp what the stakeholders will do to keep this industry booming.”