Column: Are we getting it wrong on prostate cancer screening?

James Heffernan (Courtesy photograph)

James Heffernan (Courtesy photograph) —

In December 1993, Jim and Nancy Heffernan, of Hanover, N.H., are reading each other's books. (Valley News - Robert Pope) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

In December 1993, Jim and Nancy Heffernan, of Hanover, N.H., are reading each other's books. (Valley News - Robert Pope) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com. Valley News — Robert Pope

By JAMES A. W. HEFFERNAN

For the Valley News

Published: 11-19-2023 5:30 AM

As I write these words, the prostate cancer cells that have invaded much of my skeleton are slowly but surely working to end my life. For more than six years, a succession of new drugs has enabled me to cope fairly well with my cancer, but since I have now run out of viable means to thwart it, it is sure to prevail within the next six months.

Prostate cancer plays a long game. It began working on me sometime not long after the spring of 2012, when I was blood-tested for PSA — the prostate specific antigen that signals the presence of cancer in the prostate. For something like 10 years up through 2012, this annual test had been measuring my PSA at a reassuringly low rate of 1 or less. But in that very year, the U.S. Preventive Services Task Force (USPSTF) advised that men over 70 no longer needed PSA testing at all — because prostate cancer grows so slowly that any man who catches it will supposedly die of something else first.

In 2018, the USPSTF doubled down on this advice by issuing its “final recommendation” on the risks and benefits of PSA screening for prostate cancer. While the Task Force stated that “men aged 55 to 69 should decide (for) themselves in consultation with their doctors,” it opposed PSA screening for men over 70.

Back in 2012, when my internist at Dartmouth Hitchcock passed on to me the original advice of the USPSTF, I decided to follow it and stop getting tested annually for PSA. It was the worst mistake I’ve ever made.

I’m not a medical doctor, much less a specialist in prostate cancer, and I’ve never even played one on TV. But in 2017, after skipping PSA testing from age 73 to age 78, I was diagnosed with stage 4 metastatic prostate cancer, which had climbed most of the way up my spine and into my ribs and femurs and which will stay there for the rest of my life. That was my reward for taking the task force’s advice, which remains alive and well (unlike yours truly) on the USPSTF website right now.

According to Dr. Charles Ryan, president and CEO of the Prostate Cancer Foundation, an unusually aggressive cancer might have developed between annual PSA screenings even if I had kept on getting them. But at the very least, such screenings would have raised my chances of detecting the cancer while it was still within the prostate — before it started working its way up my spine.

And what difference does this make? According to the American Cancer Society, 92% of prostate cancers are caught at the local or regional stage, when the cancer is confined to the prostate and nearby organs, and nearly all men who are diagnosed with such cancers live for at least 15 years afterwards. But among men with prostate cancer that has spread elsewhere — as mine has — the five-year survival rate is 29%.

I’ve been lucky. Thanks to a drug called abiraterone, which tames prostate cancer cells by starving them of testosterone (“chemical castration”!), I got five years of normal life and normal activity, such as swimming and playing tennis.

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But in the summer of 2022, a PSMA scan revealed that my cancer cells had broken out of their cage, and that the only way of shoving them back in again was a course of chemotherapy with docetaxel. After four rounds of docetaxel, however, a second PSMA scan revealed that my metastases were still growing, So my only option was a nine-month course of a new drug called PluVicto, which reportedly targets the cancer cells and then zaps them by means of radioactive particle. But since PluVicto zapped only some of my cancer cells, the rest are now doing their worst.

In spite of new treatments, then, metastatic prostate cancer is truly a life-threatening disease — the third leading cause of cancer death in American men. So any man over 70 who thinks he can safely skip PSA testing should think long and hard before doing so.

First, consider the arguments against testing for men over 70. For a start, PSA testing is anything but foolproof. Since PSA is a protein produced by both cancerous and noncancerous tissue in the prostate, and since PSA levels can be pushed up by noncancerous conditions such as an enlarged or inflamed prostate, the meaning of a high PSA score can be hard to judge. In fact an abnormally high PSA score accurately identifies prostate cancer only about 25% of the time. So a high score can indeed be a false alarm leading to needless biopsies and other invasive procedures, and a false alarm can also lead to complications such as incontinence and impotence. Why then even start going up this escalator?

My answer is simple. A PSA test is not the first step of an escalator leading irresistibly to needless complications. A higher than normal score is not a mandate for “needless biopsies” or any other procedure. It’s the first step of a stairway fitted with landings where you can stand as long as you want to weigh your options.

First, you need to know whether your PSA score is above the normal high for a man of your age and race. Some studies put the highest normal PSA score for all men at 4.0, but since the prostate gland generates more PSA as you grow older, other studies have argued that the normal high ranges from 2.0 for an Asian American in his 40s to 6.5 for Caucasian male in his 70s.

Suppose, then, you’re a 75-year-old white man whose PSA turns out to be 9. Before doing anything else, let alone surgery, you can get extra tests of your blood and urine that may tell you more about your condition. If you and your doctor are still uncertain, you could get a biopsy, but even if that confirms the presence of cancer in your prostate, you may not have to do anything more than check it regularly thereafter. If the cancer is growing slowly, causing no symptoms, and staying within the prostate, you can start what has been called “active surveillance” by Dr. Peter Carroll of the University of California-San Francisco. After a higher than normal PSA score, in fact, the Cancer Treatment Centers of America (CTCA) recommends a PSA test every three months and a biopsy every 15 months. If this sounds like over-testing, it’s still a long way from coping with stage 4 metastastic prostate cancer.

Of course my case could be called atypical. If only 1 in 15 men are diagnosed with prostate cancer, and if only 8% of those are found to have metastasized cancer, the average man’s chances of ending up with a cancer like mine are less than 1%. Even if we factor in my family history (my father and my oldest brother both had prostate cancer before I did), my chances rise to only 2 or 3%. But so far as I know, there are no statistics designed to measure the risks of indefinitely skipping the PSA test.

So here is my question for the task force and anyone else who claims that men over 70 should not be tested. Given the simplicity of the test, does the risk of anxiety sparked by a fallible alarm, and the cost and trouble of a CAT scan, MRI, or biopsy required to verify or falsify this alarm, really outweigh the risk of letting a cancer grow undetected for years on end until it invades the skeleton?

The task force says yes. But according to Dr. Ryan, of the Prostate Cancer Foundation, the number of men diagnosed with metastatic prostate cancer has ticked up since the task force first discredited the PSA test for men over 70 back in 2012. Also, along with several other major organizations devoted to medicine and health, the Cancer Treatment Centers of America is definitely recommending the test — not just for old guys like me but for middle-aged men like my own son Andrew (a fitness specialist in superb physical condition), starting in their early 40s.

My own experience tells me that it’s much better to know what’s going on down there than to live in ignorance for years on end — as I did.

James Heffernan is an emeritus professor of English at Dartmouth College. He lives in Hanover. His latest book is Politics and Literature at the Dawn of World War II (Bloomsbury Academic).