The following guest post is by Joshua Schneck, a healthcare marketer, patient advocate, journalist and avid cyclist. He is founder and CEO of Snow Communications, a PR and marketing agency that specializes in healthcare. He has written for The New York Times, The Minneapolis Star Tribune, Radio Sweden and other news organizations.
The number of men over 50 in the United States who were given the prostate-specific antigen, or PSA, test, declined between 2008 through 2012, and there were fewer reported early-stage prostate cancers during this period. These were the findings of a study published recently in The Journal of the American Medical Association, which linked the declines to the 2012 recommendation by the U.S. Preventive Services Task Force (USPSTF) to omit the PSA test from routine primary care for men, and the USPSTF’s 2008 recommendation to not give the test to men 75 and older. Prominent coverage of this study by The New York Times, The Washington Post and other top-tier media did a pretty good job of reporting on the study’s basic findings, and of the ongoing controversy related to use of the PSA test. The articles also reported on a second study, also published this week in JAMA, that found PSA testing had declined after the 2012 USPSTF recommendation.
The articles quoted physicians discussing the question of whether prostate cancer mortality might rise as a result of less PSA testing and fewer findings of early-stage cancer, a question posed by the studies and an accompanying commentary in JAMA. STAT, a healthcare news site associated with The Boston Globe, also covered the studies and asked in its headline, “As screening falls, will more men die of prostate cancer?” The Times, Post and STAT articles did a generally effective job of providing contrasting viewpoints on the question of PSA testing, and whether a decline in PSA testing could result in increased mortality from undetected prostate cancers.
However, as a patient who was diagnosed with prostate cancer five years ago, I was hoping the media would provide more perspective and depth on a complex issue that many men worry about and seek clarity on. Some thoughts:
Highlight the role of shared decision making. Shared decision making is the approach recommended by The American Urological Association (AUA) and also the American Cancer Society regarding PSA testing. The AUA recommends that patients 55-69 years of age or younger men at higher risk (African-American or family history of prostate cancer) discuss the risks and benefits of PSA screening with their physician before undergoing the test. Patients should learn ahead of any testing about the potential benefits and harms of the PSA test, and the fact that a subsequent biopsy may find early-stage prostate cancer that is not an immediate threat to their health. They should also learn that while surgery or radiation may be necessary for some prostate cancers, careful monitoring through an approach known as active surveillance (see below) may offer a safe and appropriate treatment option.
Shared decision making addresses the problem that occurs when men are given a PSA test without discussion and then given a biopsy which finds small amounts of early-stage cancer. In my case, I was given the PSA test without discussion or my consent. Approaching the results of a subsequent biopsy with fear and ignorance, I was extremely vulnerable when my urologist told me I needed timely treatment with surgery or radiation or I was likely to die eventually from prostate cancer. I learned later that this view that was not supported by available evidence.
Explain active surveillance. The Times took care to explain that active surveillance (or prostate cancer monitoring) is an alternative to surgery and radiation for early-stage prostate cancer. However, the STAT and Post stories did not get beyond a cursory mention of this option. Reporting on active surveillance is critical because it is considered a credible approach to many, though not all, low-risk prostate cancers. It’s the treatment approach I’ve chosen, in consultation with a second urologist and an oncologist who specializes in prostate cancer. A study published in 2014 concluded that active surveillance is safe in the 15-year timeframe, though more studies are needed to establish safety for longer periods of time.
Focus on the big picture, not just the test. Knowledgeable people have argued that the problem is not the PSA test, but how it’s used. Or overused. “I’m not against prostate cancer screening,” Otis Brawley, MD and chief medical and scientific officer of the American Cancer Society told The New York Times a few years ago. “I’m against lying to patients. I’m against exaggerating the evidence to get men to get screened.” PSA tests, however imperfect, will have an important role in the early detection of prostate cancer until a better test is found. What’s needed now is better educated patients who can work closely with their physicians to evaluate prostate cancer risk, seek testing as appropriate to their individual circumstances and values, and better understand the treatment options. The media have an important role here.