The media are reporting that next week the United States Preventive Services Task Force (USPSTF) will issue new recommendations that advise healthy men to stop getting PSA tests for prostate cancer. Let the screening battles begin!
These recommendations follow those released in 2009 by the USPSTF on mammography screening, and I hope that they are better prepared this time than last time for the barrage of criticism they faced. But the bottom line is this: when it comes to PSA testing, the evidence shows that PSA testing does not save lives even though we initially hoped that it would and did!
I know this is not what we want to hear. We want to believe that if we can just find cancers early we can save lives. But the more we learn about cancer and how it works, the more we realize how much more complicated this is.
It turns out that you need more than a cancer cell to cause clinical life threatening disease. You need the cancer cell to be in an environment that is egging it along. We are all walking around with cancer cells. Our goal shouldn’t be to find every cell with the mutations of a cancer. Our goal needs to be to find the ones that are going to do us in.
Studies show that if you look hard enough you will find prostate cancer cells in about 30% of all 40-year-old men. Studies have also shown that about 30% of women who die of something else at age 50 have microscopic breast cancer cells. If we treat every one of these cells with shock and awe (surgery, radiation, and chemotherapy) as if it were going to kill us, we will suffer the collateral damage that all these treatments have, without the benefits.
It is time we go beyond wishful thinking like, If I just get this test, I will be saved! We need to be realistic and figure out a way to determine which cancer cells or what local environment will lead to serious disease and which cancer cells can be left alone because they will never do any harm.
We like simple messages like, early detection saves lives. But the real message is complex: Early detection of a clinically significant cancer will save lives, while early detection of a clinically insignificant cancer will only cause side effects without benefit. Of course, complicated messages like these don’t make great slogans. But I think the public is smart enough to understand the truth. Don’t you?