A test for cancer............... do you want it?

There is a test for cancer you want it right? Eh...... Maybe! I had heard that the US preventive task force had recommended that we stop doing PSA Tests a couple of years ago. Despite the fact that I was personally affiliated with the very first task force in 1989 thru my residency at Johns Hopkins I really did not pay much attention to the recommendation . In 1989 when the government commissioned the first task force we residents were given unlimited library resources to research every article ever written on whatever subject we were assigned. A friend of mine researched the effect of dietary fat on cancer development, my subject was malignant melanoma. At that time the task force was unheard of and preventive medicine was not a field that many people were interested in. The first book was released without a lot of fanfare and controversy but now it is a quotable reference and considered the 'last word' on preventive measures. Despite this I paid minimal attention to their recommendations, maybe because having seen the inside I was less than impressed, that and the fact that some of the recent recommendations they made didn't seem to make sense to me. For example, a few years ago they changed the recommendations for mammogram screening, I was called by a reporter from Goodhousekeeping magazine for their breast cancer awareness month she wanted to know how the new recommendations were going to change my routine practice. I told her "not at all" because I have seen too many women in their 40's diagnosed with breast cancer to recommend starting mammograms at 50. So when the recommendations regarding PSA came out, I thought it was the same thing. If there was a test that could pick up cancer in the early stages why would we not want it? Why not indeed. I did not change my views until earlier this year. In March I attended a session on the use of PSA and prostate cancer at Temple University. On stage was a Family Physician,a regular Urologist, an Oncologist and a Reconstructive Urologist. The only person who thought that doing PSAs was a good idea was the 'regular' urologist. The first guy had tables of all the complications of treatment for prostate cancer and studies that showed no difference in mortality in patients who had the test and those who didn't. The most shocking was the reconstructive guy who simply declared "I clean up the mess left by urologists who unnecessarily treat the prostate cancer. Oh, you know, urinary incontinence, erectile dysfunction, pain and so on!" I have since thought about two patients I have had in my practice, the first one was a guy I did the test on when it first came out. I always remember having to call him on Xmas eve with the news because I was leaving the country. He was 39 at the time (earlier than the recommended age for screening). He started with a PSA of 16 (normal being under 4), several years and many procedures later the number continued to climb. He was one of only two men I have ever sent for a mastectomy (side effect from the treatment). The primary could never be found but his number just kept going up, eventually a year before his death it was found spread to his nervous system. He always said if he knew then what he knew 10 years later he never would have had the surgery or the hormonal therapy. He said the cure was way worse than the disease. Another gentleman who's PSA I checked around the same time had a level of almost 5, he and his wife were moving to Gettysburg, Pennsylvania, I gravely advised them to get it rechecked when he found a new doctor, they did not. They showed back up in my office almost a decade later saying they had not been seeing any doctor but he had to have a level done 3 weeks before for life insurance and it was 54. I moved into overdrive, immediately repeated the level (it was 65), got him a same day appointment with a urologist and shuttled him into treatment. He is doing well, having chosen some minimally invasive modalities. I wonder what the outcome would have been if we had detected the cancer earlier. Would we have improved the quality of his life over the past 12 years or would modern medicine have hastened its demise? I do know I wish I had found the first patient's elevated PSA much later, even though at the time I thought I was being diligent. For news about the updates on Prostate Cancer diagnosis see the next blog. Be Well!