Screening for cancers: Too much talk, not enough action
PSA knocked, but is it more successful than other cancer screening tests?
By Howard Wolinsky
Screening gets lots of ink and airtime as the way to detect cancers early.
But slow down.
Depending on the cancer in question, the reality is few of us bother with screening tests, such as the prostate-specific antingen (PSA) blood levels to detect potential cancers early as well as to monitor our lesions in Active Surveillance.
A just-released report from the University of Chicago’s NORC, an independent, nonpartisan research group, found that screening sadly represents too much talk but not enough action to detect cancer—to paraphrase a song debuted by country singer Hank Williams Jr. back in the ‘90s.
The U.S. Preventive Services Task Force (USPSTF), an independent agency, is an arbiter of screening for primary care physicians.
The organization assesses the benefits and risks of screening. It does recommend screening for breast, cervical, colorectal, and lung cancers. But it’s no fan of prostate-specific antigen (PSA) blood levels to screen for prostate cancer.
Like many critics, the task force has been concerned about PSAs resulting in overdiagnosis and overtreatment of prostate cancer.
In 2012, the task force advised against PSA screening. It gave PSA screening a D, a failing grade.
After urologists and patient advocates protested, the organization in 2018 revised its Grade for PSA to a still feeble C.
That’s not exactly a ringing endorsement. Did the task force throw out the baby with the bath water? USPSTF says that’s between you and your urologist?
“The decision to be screened for prostate cancer should be an individual one,” the task force said.
But the task force, more or less labeled, PSA as a pariah, the screening equivalent to political outcasts such as Belarus, Iran, North Korea, and Zimbabwe.
However, NORC examined screening for all five cancers, including PSA screening.
Ironically, NORC shows that screening for prostate cancer may be the most successful of screening approaches. Check out NORC numbers on those who undergo screening.
NORC reports that 77% of prostate cancers are found through screening. Compare that to percentages for other cancers found through screening: 61% of breast cancers, 52% of cervical cancers, 45% of colorectal cancers, and a super-low 3% of lung cancers.
Overall, ignoring prostate cancer, NORC reported that only 14% of cancers are found through screening.
The recently implemented Cancer Moon Shot by President Obama and then President Bidentand the previous 50-year-old War on Cancer, which came on President Nixon's watch, no doubt trying to distract from a hot war blazing at the time in Southeast Asia, haven’t done much to move the needle on screening.
When cancer is detected in earlier stages, survival rates are four times higher compared to late-stage detection, according to NORC.
(Note: Some experts maintain that survival rates can be misleading since diagnosed patients are starting the survival clock early, leading to screening appearing more successful than it really is how long would they have survived if screening didn’t detect it? We can save that debate for another day.)
The public has not exactly been enamored of PSA screening. Even before the task force weighed in, the proportion of candidates for PSAs was low.
Dr. William Catalona, Northwestern University (Go Cats!) Geinberg School of Medicine, the “father of PSA screening,” told me over the weekend the best PSA rates he’s heard of were as high as 73%. in men in their 50s and 60s in Ontario in 2011/12. “But this estimate is unrealistically high,” he conceded.
He pointed to a more realistic study of patients in the Veterans Health Administration, America’s largest integrated healthcare system, that found that PSA screening has dropped from 47% in 2005 (pre-USPSTF’s D rating) to 37% in 2019 (a year after the latest USPSTF C grade).
The VA cohort was 4.7 million men in 2005 and increased to 5.4 million in 2019.
Researchers clearly found a drop in PSA use in their study, which appeared in JAMA Oncology on Oct. 24, 2022.
ResearcherAlex Rose, a radiation oncologist at the University of Michigan (Go Blue!), and colleagues concluded: “Higher facility-level PSA screening rates were associated with lower metastatic prostate cancer incidence 5 years later … Higher long-term nonscreening rates were associated with higher metastatic prostate cancer incidence 5 years later …”
So roughly they saw a decrease from half to one-third of candidates in the huge VA system opt to undergo PSA testing. I suspect rates are similar in the community at large. PSA is not exactly a world-beater, but it seems effective when it is used properly in conjunction with MRIs and biopsies.
Also, researchers noted that metastatic prostate cancer incidence increased from 5.2 per 100 000 men in 2005 to 7.9 per 100 000 men in 2019.
USPSTF’s rulings have been blamed. But let’s face it, PSA testing, on its own, is not winning any popularity contests.
PSAs can open Pandora’s box, leading to biopsies, which themselves pose risks, such as sepsis and other infections, and can expose patients to unnecessary treatment and its side effects, such as impotence, incontinence, and more. The overdiagnosis problem—which some doctors prefer to dis—and the overtreatment problem.
I know several physicians who personally shun PSA testing—while discussing in a neutral fashion with their patients—because they don’t want to expose themselves to this cascade of risky events along the PSA trail.
(In 2010, I was a “good patient” and underwent a PSA, which was just under 3.95, almost in the PSA grey zone of 4-10. Then, I underwent a 14-core needle biopsy, which led to a diagnosis of low-risk prostate cancer in a single core (less than 1 millimeter).
(The first urologist recommended an unnecessary prostatectomy. STAT. I lucked into an active surveillance program at the University of Chicago. These days, with MRI scans added to PSAs, I probably never would have had a biopsy let alone been diagnosed.)
A final word from NORC on screening overall:
According to NORC estimates, 57% of all diagnosed cancers currently do not have a recommended screening test. These cancers are typically found in patients who are symptomatic, perhaps with cancers in later stages that are more difficult to treat. In total, these diagnoses account for 70% of cancer-related deaths.
So there’s a huge gap in screening.
“Cancer treatments have vastly improved over the last few decades, but the health system’s ability to screen for cancer, which is essential for early diagnosis and effective treatment, still has a long way to go,” said Caroline Pearson, senior VP at NORC. “There need to be more screening options to catch more cancers and improve outcomes for patients.”
Amen.
Are invaders still snatching prostates?
By Howard Wolinsky
Don’t miss the AnCan webinar that will answer the question posed in the headline.
The program at 8-9:30 p.m. Eastern Jan. 30 features Dr. Mark C. Scholz, co-author of the groundbreaking 2010 book: “The Invasion of The Prostate Snatchers.”
Scholz’s program is entitled, "Invasion of the Prostate Snatchers: 13 years later. An evening with Dr. Mark Scholz." To register, click here: https://bit.ly/3VL1aiP
Spoiler alert: Things are better, but the invaders still are snatching and nuking large numbers of prostates unnecessarily.
AS 101 Episode 3: A prostate cancer diagnosis with the father of AS
By Howard Wolinsky
When we last saw Larry White in Episode 2 of the video cliffhanger, Active Surveillance 101, he and his wife Nancy were coping with his rising PSA.
Dr. Laurence Klotz, “the father of AS, advised them about Larry’s options. Now on to Episode 3: The Whites meet again with Klotz about what’s next up for Larry regarding AS.
AS 101 is a series of 20-30-minute conversations between the Whites and leading prostate cancer experts covering essential questions for patients considering AS.
The goal of this series is to reach AS candidates, including the newly diagnosed and those who have not yet been diagnosed with prostate cancer but have rising PSAs (prostate-specific antigen) blood levels, to provide them with an introduction to AS.
Active Surveillance Patients International (ASPI) will premier the AS 101 Episode 3 video on Saturday, Jan. 28, 2023, at 12 p.m. Eastern. Register here: https://bit.ly/3ZeATME Don’t forget to bring some popcorn and Junior Mints.
The session will be followed by a Q&A, a discussion of the video, and a support session.
In 2022, ASPI honored Klotz, of the University of Toronto, as the first recipient of the Gerald Chodak Active Surveillance Pioneer Award. The late Dr. Chodak was Klotz’s mentor and also was ASPI’s first medical advisor.
The Active Surveillance Coalition (ASC) created the series called Active Surveillance 101 to teach the basics of AS to the newly diagnosed patients and to those in the “gray zone” with rising PSAs who are awaiting biopsies. Programs are brief, lasting 20-30 minutes without slides.
For the earlier videos go to: https://aspatients.org/a-s-101/.
At least four more programs are being developed, including one on biopsies and pathology reports with Dr. Jonathan Epstein, the top-gun pathologist on prostate cancer from Johns Hopkins University. Others deal with genetic and genomic testing and imaging, including MRIs and micro-ultrasounds..
AS 101 was created under the banner of the Active Surveillance Coalition, whose members include ASPI, AnCan’s Virtual Support Group for Active Surveillance, Prostate Cancer Support Canada, Prostate Cancer Research Institute, and The Active Surveillor newsletter.