Guest Post: PSA Screening Still a Bad Idea

One of the unsung heroes of modern medicine is Richard J. Ablin, professor in the Pathology Department of the University of Arizona. The discoverer of prostate-specific antigen (PSA), Dr. Ablin has spent decades warning doctors and the public that the PSA test is not only useless for population screening for prostate cancer, but is incredibly harmful. For every man whose life is saved via early detection of a deadly tumor, hundreds are maimed by treatments for tumors that were never going to hurt them.

The false positive rate for PSA is around 20%, meaning that about one in five men undergoing the test will be told they probably have prostate cancer and will require a dangerous biopsy to confirm the diagnosis.

Impotence and incontinence rates following treatments for prostate cancer are the range of 50-80%, and the biopsies that follow a positive PSA test can themselves turn slow-growing tumors into malignant hazards. And, on top of it all, the PSA test is not specific for cancer!

His book, The Great Prostate Hoax: How Big Medicine Hijacked the PSA Test and Caused a Public Health Disaster, is a deep dive into the corrupt and disingenuous nexus of urology and industry. If you are a man over 50, or know one, this book can be a lifesaver.

Recently the US Preventive Services Task Force upgraded their rating of the PSA test from a D (basically, it sucks), to a C (let's talk about the risks and benefits). Dr Ablin asked me to post his response on Plant Yourself in the hopes that it will save lives. So heeeere's Dr Ablin:

In a troubling reversal of its previous recommendation in 2012, of a “D” classification against the use of prostate-specific antigen (PSA) screening, the US Preventive Services Task Force has issued a new recommendation in April this year of a “C” classification, whereby, that doctors should have a meaningful conversation with male patients between the ages of 55 and 69 about the risks and benefits of undergoing PSA screening. This is a bad public health decision that will only increase the use of an intrinsically flawed test as previously discussed on TriangleBeWell (26 March 2016 [http://trianglebewell.com/wt-015-richard-ablin-phd-on-the-great-prostate-hoax/]) that—as also formally noted by the Task Force—does far more harm than good.

The Task Force’s new Draft Recommendation centers on a doctor-patient informed-decision conversation about PSA screening, across all social and demographic lines. Given the complexity of this issue, it is not feasible for a busy community doctor to elucidate the full spectrum of detailed clinical issues involved in PSA screening (Brett and Ablin. NEJM, 365,1941, 2011). Inequities and variability will abound, as is borne out by data. For example, a new study Turini et al. Urology, http://dx.doi.org/doi:10/1016/j.urology.2016.12.069 (accessed 10 April 2017) that looked at 200,000-plus men found that 37 percent were told only of the advantages of PSA compared with 30 percent who were advised of advantages and disadvantages. More striking, 33 percent were not informed of either. These men were more likely to be Hispanic, not high school graduates, and of low income. Basing a potentially life-changing medical decision on incomplete information will have profound consequences for men across the country.

The Task Force indirectly suggests that doctors and patients should revisit the decision to screen (or not screen) in a Table presented in the Draft Recommendation of estimated effects of PSA-based screening for prostate cancer on men observed in the European Randomized Screening of Prostate Cancer (ERSPC) trial.  A relevant caveat here (Haines et al. BMJ, 353, i2574, 2016) is that the ERSPC trialists have yet to de-identify patient data and make it available for independent review. Without examining individual patient data, it is impossible to confirm any benefit of PSA screening or the validity of the data.

Before the Draft Recommendation goes into effect, doctors across the country need specific guidance from the Task Force on how to conduct informed-decision-making conversations with their patients about PSA testing. It is recommended that the Task Force create a discussion summary similar to the Table included with the Draft Recommendation. Thereby all patients will receive consistent information so that they can make their own assessment of the potential benefits or harms resulting from the PSA test.

Richard J. Ablin, Ph.D., D.Sc. (hon), Dr. h.c.

Ronald Piana

Richard J. Ablin is Professor, Department of Pathology, University of Arizona College of Medicine, The Arizona Cancer Center and BIO5 Institute, Tucson, AZ  85724

Ronald Piana is a Freelance Science Writer, Huntington, NY  11743

3 Responses to “Guest Post: PSA Screening Still a Bad Idea”

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  1. Chris O'Neill says:

    “doctor-patient informed-decision conversation about PSA screening”

    In practical terms, informed decision making means that men who do not plan to ever have sex again and who have no problem wearing incontinence pads for the rest of their lives should definitely consider unproven strategies such as PSA screening and acting on its results.

  2. The PSA test is NOT a hoax. But many hoaxsters use it to scam the public. It does a great job of highlighting that a prostate is upset about something. (Two trivial candidates are the physical trauma of running or bicycling too much.) It is up to the patient and his physician to find out what that “something” is and fix it. The customary alternative is biopsy; a surgery that killed 8 Americans last year. Pissing into a cup for the PSA test never killed anyone.

    I recommend using a genetic and annual PSA test to screen for prostate potential which should be considered positive on a sliding scale of > 4-8 from age 40-80 years. Then if routine insults like toxins/alcohol/tobacco/diet and exercise corrections don’t solve the problem, a +3 tesla ultrasound/MRI fusion picture will show with great clarity any structural prostate problems. AND IT IS HARMLESS TOO. If the picture reveals any suspicious areas then a biopsy, targeted by the picture, will provide a highly reliable determination at minimum harm and risk.

    Stop badmouthing the PSA test. It is a neutral tool. Use it correctly and it will avoid needless interventions while potentially saving your life.

    • Howard says:

      Thanks for your comments, Stephen. Have you read Dr Ablin’s book? In it he makes clear that it’s not the test itself, but the way it’s used by the pharmaceutical industry and urology professions that is the problem. Also, most (false) positive PSA tests automatically lead to needle biopsy, which has been shown to spread cancerous cells.

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