Shortly before financier Michael Milken was released from prison in early 1993, he had a thorough physical exam and was pronounced healthy. But Milken, 46, had lost a friend to prostate cancer. So he asked the doctor to perform a blood test he had heard about which measures PSA, or prostate specific antigen. His internist didn't recommend the test for a man so young, but Milken insisted. When the test showed Milken had very elevated PSA levels, he consulted a urologist, who found Milken had an aggressively growing cancer.
Prostate cancer is now the No.2 cause of cancer deaths in U.S. males. Some 200,000 men will be diagnosed with the disease this year, and almost 40,000 will die of it. On its face, Milken's story suggests PSA should become part of a routine battery of can't-hurt annual screening tests for healthy middle-aged men. Plus, a recent study in the Journal of the American Medical Assn. validated the test's ability to find the majority of prostate cancers. But a growing minority of doctors are not convinced PSA screening should, in fact, be routine.
SLOW GROWTH. Here's what's going on: Until the PSA test became available several years ago, prostate problems were typically discovered when a man developed symptoms, such as trouble urinating, or when a physician detected an abnormal prostate during the infamous "digital-rectal exam." (For this procedure, the doctor inserts a gloved finger in the rectum to check what should be a walnut-size gland located just beneath the bladder.) But stories about well-known prostate cancer patients such as Milken, Senator Bob Dole (R-Kan.), and the late Time Warner Chairman Steve Ross, are prompting scores of middle-aged men to demand PSA screening tests--even when they are symptom-free.
Urologists and internists alike agree that men, usually starting in their 40s, should have a yearly rectal exam. Those with symptoms or detectable prostate nodules should receive a full workup, including a PSA test. Many urologists cite cases such as Milken's as justification for routinely checking PSA during annual physicals, much the way gynecologists order mammograms and Pap smears for adult qomen. Their hope is to catch prostate cancer early enough to cure it or at least slow its progress. Treatments include radiation, chemotherapy, hormonal therapy, surgical removal of the prostate, and other new techniques.
One reason for the dispute over PSA testing is that prostate cancer is often slow-growing--so slow that most men who develop it actually die of something else. Unfortunately, PSA levels don't always distinguish the slow-growing form from a more aggressive disease that should be treated immediately. It will help if scientists succeed at current efforts to develop a test to flag the more virulent form. But the screening issue will remain controversial until a crucial question is answered: Will early detection by PSA and subsequent intervention lower the death rate from pro state cancer? A huge study launched by The National Institutes of Health should answer that question, but the results won't be clear for a decade or more. Until that's resolved, one fear is that doctors may simply be identifying incurable cancer earlier, then doing procedures that lessen the quality of the patient's remaining years.
Internists in particular worry that routine PSA screening will frighten huge numbers of men for no purpose. The JAMA study, for example, showed false positives in 10% of the healthy men tested. White River Junction (Vt.) internist H. Gilbert Welch, an expert in early detection, notes that a positive PSA test often results in further costly, invasive tests and procedures with very serious side effects that can include incontinence and impotence. "Do you want to enter this loop when the chances of being a false positive are very real?" he urges patients to ask themselves. Potential complications are not just physical: Some men become obsessed with getting surgery for cancers that might be better treated by watchful waiting.
SIDE EFFECTS. Urological oncologists such as Peter Carroll, associate professor of medicine at the University of California at San Francisco, say they believe early identification and treatment will bring death rates down. But Carroll also acknowledges the uncertainties and urges men not to overreact to unusual cases such as Milken's. He believes men must be fully informed about the probabilities and side effects associated with treatments and make decisions based on their unique situations. For example, men in their 70s are so unlikely to develop a prostate cancer that will kill them, many urologists tell them not to bother with PSA. But an active 40-year-old married man with a family history of prostate cancer must weigh other factors.
Prostate cancer information and support groups are helping men sort through these quandaries: There, they can talk to others who have made--and now are living with--these tough decisions. A number of books are available, too, such as Prostate Cancer: Making Survival Decisions by Sylvan Meyer and Seymour Nash (University of Chicago Press, $19.95). They may raise issues a man can discuss with his doctor before taking a PSA
Confused about whether to take the prostate specific antigen test? Here are resources for men concerned about prostate cancer:
THE AMERICAN CANCER SOCIETY 800 227-2345 Sponsors prostate cancer support groups for men called Man to Man and groups for men and their partners called Side by Side; for local organizations, call local ACS chapters
THE AMERICAN FOUNDATION FOR UROLOGIC DISEASE 800 242-2383 Has a Prostate Health Council and Prostate Cancer Support Network that can provide general information about the disease and ongoing research
US TOO INTERNATIONAL 800 808-7866 Coordinates support groups in most major cities and publishes a quarterly newsletter, The Prostate Cancer Communicator, addressing treatment options and psychological and social aspects of prostate cancer