Screen with care

The screening test checks for Prostrate Specific Antigen (PSA) in the patients blood,and levels higher than 4 ng/ml,are said to be indicative of possible prostrate cancer. This needs to be confirmed through biopsy. An article published in the New England Journal of Medicine on August 16 has pointed out that the number of quality life years enjoyed by a patient diagnosed early with prostate cancer is not significantly different from those by patients diagnosed later.

Even before the disease becomes symptomatic,there may be side effects of biopsy,eventual surgery and radiation on the body.

Eveline A M Heijnsdijk,PhD,from the Erasmus Medical Center in Rotterdam,Netherlands,and colleagues found that in men between 55 to 69 years old,nine prostate cancer deaths were prevented for every 1,000 men screened,and they gained 73 life years. But the number of quality life years gained per 1,000 men was only 56,a reduction of 17 years. The authors observed that the benefit of PSA screening was diminished by loss of quality life years,owing to post-diagnosis long-term effects.

The reservations are not new. From 2008,urologists have been questioning the need for screening in young men.

The test,considered to be one of the most sensitive tumour markers,would detect cancer at an early stage. Some of these cancers may not become symptomatic or have the life-threatening implications associated with the disease, said Dr P N Dogra,head of urology at AIIMS,and former president of the North Zone of the Urological Society of India. The specificity of the test not being very high,there were also cases of false positives,high PSA levels were detected,but no cancer found. Treating these cancers then,would lead to impotency and other side effects of radiation and cancer surgery. Thus,a universal age bar of 50 years was recommended for screening prostrate cancer.

According to president elect of the Urology Society of India Dr R M Meyappan,The PSA Test is not routinely done as screening procedure,but is advocated to all patients who have lower urinary tract symptoms and are over 50 years old. The test is organ-specific and not tumour-specific and it may be elevated even in benign conditions of the prostate,other than malignancy.

Reservations in the USA

In May this year,a US task force constituted to look into PSA took these concerns a forward by recommending a complete ban on PSA. The recommendations of the US Preventive Services Task Force (USPSTF) published in the Annals of Internal Medicine in May said,The USPSTF concludes that there is moderate certainty that the benefits of PSA-based screening for prostate cancer do not outweigh the harms. The USPSTF now recommends against PSA-based screening for prostate cancer in all age groups.

These recommendations were based on two trials: one in USA which found no reduction in deaths after screening and one in Europe which said 1,000 men would have to be screened to prevent a single death.

Given these concerns,with rising awareness about cancer in India in the past decade,what should Indian men do? Experts say the findings of the report should be treated with caution,but recommend treading on a safe middle line,nonetheless. Dr Dogra says,Many problems associated with trials were taken into account by the US group. But we should note that most of these problems have been raised by people who would sustain serious commercial losses by such a ban on PSA.

Why patients worry

Doctors now say symptomatic patients have difficulty in passing urine,blood in the urine or burning sensation while passing urine,should undergo the test only upon the recommendation of a urologist. Dr Samir Khanna,consultant in uro-oncology at Delhis Rajiv Gandhi Cancer Institute (RGCI) says,We find a lot of panic-stricken people coming to us with PSAs done on the advice of general practitioners. These days everybody knows about PSA and its a simple blood test,so it is advised frequently. The problem is high PSA levels may not always indicate cancer.

Dr S K Singh,professor of urology at PGI Chandigarh and secretary of the Urology Society of India,says,With the limited evidence of prostrate cancer,every suspected case requires personalised management. Evaluation of patients with serum PSA needs to be individualised. PSA has a definite value in staging the cancer prostate,monitoring the response of therapy and follow up. The recovery rates of the cancer are better if detected early. But it is not possible to make a categorical statement in this context since the biological behaviour of the cancer prostate is variable. The science is grey in many aspects and understanding is increasing slowly, Dr Singh said.

Grey areas

DR KHANNA said since incidence of prostrate cancer in India is not as high as in the West,the yield rate of screening was significantly lower. This leads to over 95 per cent of unnecessary biopsies from the prostate. It also involves a lot of medical resources,is a time-consuming process,and above all,puts psychological stress on the patient. The multiple-core biopsy from the prostate through the rectum is an invasive procedure,associated with morbidity such as pain,discomfort,bleeding,and infection, Dr Singh says.

He recommends proper counselling of a patient with raised PSA levels,on the effects of biopsy if the digital rectal examination (DRE) done by a urologist is not abnormal.

Symptoms of urinary tract infections are often confused with prostrate cancer. Presence of infection in the blood may induce a higher PSA level,and in this case,repeat PSAs should be done after the infection has been controlled. It is important to understand that PSA is not the be all and end all. Doctors need to exercise their clinical judgement regarding the stage at which PSA levels should be used to recommend a biopsy or even cancer treatment, Dr Khanna says.

Dr Rajinder Yadav,senior consultant in urology at Max Hospital in Saket,says at times,doctors discretion assumes the most significant role. Just getting a PSA may not have any repercussions. But a lot of times,biopsies are prescribed indiscriminately and when they are not conclusive,doctors take a defensive approach and recommend removal of the prostrate. In 10 to 15 per cent cases,after the prostate is taken out,a histopathology shows no malignancy.

Patients who have a family history of prostrate cancer,or even parallel descendency in family,are also advised to take the test. Private hospitals now offer package deals in cancer screenings. While many,like RGCI,do not offer PSA in the deals,others,like Max Hospital,offer it. With the evidence we have,it is better to avoid doing the test on young,asymptomatic men,and advise them against it, Dr Dogra said.

With every voice of dissent,there are experts who point out that it is too early to dismiss PSA. Dr Rajeev Sood from Max Hospital says,There is no doubt that PSA is a good tumour marker test. So far,we can only say that it should be performed with caution. Patients who are above 40 years,or with a family history,should definitely get it done once a year. He said such annual test results provide consultants a PSA velocity,or the rate at which PSA is changing,which provides enough evidence to recommend treatment.

Doctors also say that alarm bells in the West are prompted by a cost-versus-benefit analysis. In USA,the state has to fund the screenings and treatment recommended by doctors. So their concerns are triggered by the cost-versus-benefits in terms of numbers of patients. In our country,the government is not funding screenings for any cancer, Dr Khanna from RGCI said.

A patients dilemma,

A 54-year-old Delhi government employee who requested anonymity,says he had been undergoing PSA tests once a year for the last four years. Coming from a family of doctors,he and his cousins took the tests together at a South Delhi hospital. His PSA levels had always hovered between 4-5,until last January,when they suddenly shot up to 30.

I went to three consultants in leading Delhi hospitals,one of them from the government sector. All three recommended biopsy,after putting me through repeat PSA tests,though I had none of the obvious symptoms associated with cancer. A biopsy is very painful,so I had my reservations,but when three doctors recommended it,I went ahead, he told Newsline. Laboratory results confirmed his worst fears,as he tested positive for CA prostrate,or prostrate cancer.

Again I took several opinions. I read online that PSA and biopsy results may not be conclusive,so I asked my doctors. But for all the medical literature I found,all the doctors took a defensive approach,and recommended I undergo surgery, he says.

He now describes his situation as the classic Catch-22. When it is a question of life,does one trust scientific literature from another continent,or go by what doctors here recommend? After all,what was the purpose of the screening if I ignored the evidence it presented? he says.

Six months ago,he underwent the procedure,and a histopathology of the tumour confirmed the doctors suspicions. Today,he dismisses all scepticism about the test. Cancer screening is perhaps the only way to manage this disease. If I had not taken the test,who knows whether my cancer would have been detected later,when the risk of metastasis would be heightened? One should trust doctors,but ultimately prevention is better than cure. We should not forget that every life is precious, he says.