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Tackling the contentious issue of PSA testing

I've been in the medical writing business for about 25 years, and there are few issues that have been as contentious as one I tackled recently for my article in Stanford Medicine magazine - the PSA test for prostate cancer. It is understandably an emotional issue for men, as it deals with an insidious disease that is responsible for 28,000 deaths a year. No man wants to hear that he has prostate cancer. But the question is, is the PSA a truly useful way for men to learn their status?

The perspectives on both sides could not be more divergent. Some argue the PSA, which is not a very precise test, represents a classic case of overscreening - an overused test that adds millions in unnecessary health care costs. Many men whose PSA numbers are high may not have cancer at all or a cancer so benign that it does not demand treatment, critics say. And yet those men, fearing the worst, may opt for treatments that can cause them permanent harm, such as impotency or incontinence. For that reason, the U.S. Preventive Services Task Force (USPSTF) has strongly recommended against the test, saying it causes more harm than good.

On the other side are those who believe the PSA is still a worthwhile tool, a good predictor of who is likely to develop the disease, particularly aggressive disease. In the two decades since it's become widespread, they note, more men with advanced disease have been spared from death. One reader also criticized the USPSTF's methodology, saying the group used  faulty statistics to overstate the harms of screening.

James Brooks, MD, a professor of urology at Stanford and expert on prostate cancer, takes a middle ground. He believes the test is an indicator of risk, just as a blood pressure test is an indicator of risk for heart disease. But he doesn't press his patients to pursue treatment just because their PSA numbers seem questionable at first, especially if a biopsy suggests they have low-grade disease; rather, he encourages those to consider active surveillance, in which the cancer can be regularly monitored.

There is one point on which both sides agree: It's important for men to make informed decisions. Men should talk to their doctors before they get tested and if they do, spend some quality time afterwards discussing the results before they pursue treatment. And the other point of agreement: We need better tests.

Previously: The money crunch: Stanford Medicine magazine's new special report, Ask Stanford Med: Answers to your questions on prostate cancer and the latest research and To screen or not to screen? When it comes to prostate and breast cancers, that's still the question

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