Dilemma

There’s an old adage that goes, “Never talk about your health… unless it’s good… unless you’re talking to your doctor.” I usually follow that advice, but I’m making an exception here.

This week I’m getting a prostate biopsy. My PSA is out of whack. PSA stands for Prostate Specific Antigen, a cancer marker in men – the higher the number, the greater the chance a man has prostate cancer. Most doctors use 4.0 as the cutoff. Below that – assuming there are no symptoms – they’ll say, “See you next year.” Above that and they want more tests to rule out cancer.

You might wonder, “Is prostate cancer a big deal?” Prostate cancer is second to lung cancer as a cause of cancer death in men (additional info). About 1 in 6 American men will be diagnosed with it; of that group, about 1 in 5 men will die from it. However, most prostate tumors are so slow-growing that a man having one will die of something else before the cancer kills him. But doctors have difficulty determining which kind of prostate cancer a patient has, so they err on the side of caution. They over-treat. And because treatment has serious side effects such as impotence, incontinence, and even premature death, over-treating and harming many men unnecessarily in order to save a few has become a controversial subject. Nevertheless, when my doctor looked at my latest PSA test result he remarked, “This test is screaming for a biopsy.”

The prostate is located below the bladder and in front of the rectum. To biopsy it, the doctor will locate my prostate by inserting an ultrasound probe into my rectum and then take tissue samples by shooting hollow, steel needles through my rectum and prostate. He’ll take 12 tissue samples in 12 locations. It sounds positively medieval.

My doctor ran through a list of possible complications … pain, bleeding, infection requiring a course of antibiotics, and so on. But those complications are not what bothers me most about a biopsy. Rather, it’s knowing that a biopsy could be the first step on a road to surgery or radiation or hormone treatments or chemotherapy or any of the other possibilities that come with a diagnosis of prostate cancer: a panoply of treatments that may do absolutely nothing useful for me and may be – indeed, are likely to be – completely unnecessary and quite harmful.

The U.S. Preventive Services Task Force recommends men should not get routine screening tests for prostate cancer. They say routine screening using the PSA blood test results in "small or no reduction" in prostate cancer deaths. They give the PSA blood test a “D” rating, meaning "there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.” This is just the latest of several studies showing little or no benefit from routine screening. On the other hand, there is no shortage of men who will argue that routine screening saved their lives.

To test or not to test? To biopsy or not to biopsy? Doctors who deal with individuals advise one answer; scientists who study populations advise a different answer. That disagreement sets up a dilemma for men. A few years ago I decided to get the PSA screening every year. And what was the point of getting the PSA if I’m not going to follow up with a biopsy when the PSA is “screaming” that I need one?