Ron Viarengo is pretty clear about screening for prostate cancer. He doesn’t want it.
Not the prostate-specific antigen test and definitely not the digital rectal exam. Both are routine procedures performed in about three-quarters of U.S. men older than 50.
So, news Wednesday that scientists have moved a step closer to creating a genetic test to detect the disease did nothing to sway Viarengo, a 64-year-old Vermont manufacturing sales representative.
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He’s among a minority of American men who’ve weighed the pros and cons of prostate cancer screening tests — and decided that it’s better not to know.
“I think my basic philosophy is that there were way too many unknowns about it,” said Viarengo, who first considered prostate testing last summer. “I just decided that I’m not going to worry about something that is quite nebulous.”
It may be promising that American and Swedish researchers have identified genetic markers that appear to raise the risk of prostate cancer nearly 10 times in men with a family history of the disease, as reported in a new study in the New England Journal of Medicine.
But Viarengo said he buys the arguments of some medical experts who warn that current prostate cancer screenings are imprecise at best — and that diagnosis can prompt drastic treatments that can result in impotence or incontinence, all for an often slow-growing cancer that may never cause symptoms or death.
“If they could definitively tell me, then maybe I would take it,” Viarengo said.
It’s an unusual stance in a country where PSA testing has become nearly universal since its introduction more than two decades ago. Advocates of early screening abound, noted Stephanie Chisolm, patient education director for the American Urological Association Foundation.
“There are doctors who believe you should screen everyone who has a prostate,” Chisolm said.
Passions run high on the subject, especially among survivors who believe screening saved their lives — and doctors glad to have tried every intervention.
Other doctors, however, argue that there’s no evidence that current screening tools reduce prostate cancer deaths and that the treatment can be worse than the disease. Treatment options can range from surgery to radiation therapy to “watchful waiting,” a strategy of keeping an eye out for rising PSA levels.
Potential side effects of treatment must be considered as an outcome of screening, said Dr. Barry Kramer, associate director for disease prevention at the National Institutes of Health. He’s one of the most vocal critics of routine prostate screening.
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“We’re identifying huge numbers of men with prostate cancer with no good or reliable way to tell which ones really benefit from diagnosis or treatment,” Kramer said.
Although results of a 15-year longitudinal study of prostate screening efficacy are still out, smaller projects have cast doubt on the procedures.
For instance, a 2006 study of nearly 72,000 men older than 50 at 10 Veterans Affairs hospitals in New England found that those who had been screened for prostate cancer were no more likely to survive the disease than those who weren’t.
Kramer called Wednesday’s genetic marker study “a piece of the puzzle,” a view echoed by Dr. Edward P. Gelmann, director of the Prostate, Lung, Colon and Ovarian Cancer Screening Trial. In an essay accompanying the study Wednesday, Gelmann acknowledged the new work is only a small step toward reliable detection for prostate cancer. The disease is diagnosed in more than 218,000 U.S. men a year and kills more than 27,000, according to the National Cancer Institute.
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“What we cannot yet derive from these studies is an easily applicable test that will assist in identification of men who are at high risk for prostate cancer,” wrote Gelmann.
Still missing in the research, Gelmann noted, are crucial markers that would distinguish between aggressive cancers likely to be lethal and the more common kind: slow-growing cancers that can linger for years. Although one in six men will be diagnosed with prostate cancer in his lifetime, only one in 33 men will die from the disease, according to the Mayo Clinic.
No ‘magical PSA’The value of prostate screening has long been a subject of debate among medical experts. The problem is that the most common screening tests offer imprecise results. Digital rectal exams can easily miss cancerous growths. Blood levels of PSA, a protein made by the prostate gland, can be high even when there is no prostate cancer, and they can be low even when cancer is present.
“The problem is there is no threshold of PSA that has good sensitivity and good specificity at the same time,” Kramer said. “There is not a magical PSA.”
That leaves ordinary men like Viarengo confused about whether to be screened. It doesn’t help that they receive conflicting information from groups like the American Cancer Society and the American Urological Association, which recommend that doctors offer screenings for all men after age 50, and groups like the U.S. Preventive Services Task Force, which says there’s not enough evidence to advise routine screenings.
Many men agree to prostate screening without thinking much about it, said Dr. H. Gilbert Welch, a professor at Dartmouth Medical School and author of the book, “Should I Be Tested for Cancer? Maybe Not and Here’s Why.”
Advanced cancer is such a horrible disease and the benefit of early detection makes such intuitive sense, “it takes a while for people to realize there are some downsides,” Welch said.
On the other hand, some men decline screening without much thought, noted Chisolm, of the American Urological Association Foundation.
“There are a lot of people who are nervous and afraid of what happens if they find it,” Chisolm said. “When I’m out and about I talk to people who basically say, ‘Hear no evil, see no evil.’ They say, ‘I don’t want to know. We’re all going to die of something.’”
But men who have a chance to talk in detail with their doctors about the pros and cons of screening benefit most, said Dr. Robert Reid, a primary care doctor with Group Health Permanente in Seattle, and a fellow of the American College of Preventive Medicine, which recommends that men carefully consider the question with their doctors.
Burden of knowledge“The question is, ‘Do you really want to know and have the burden of knowing whether we’ll treat it or not?” Reid said.
For many men, the answer is unequivocal: Yes.
Larry Forney, 54, a college professor in Moscow, Idaho, said he and most of his male friends regard prostate cancer screenings as a necessary part of personal health care.
“PSA measurements are not dinner table talk, but the men I know are certainly aware that PSA should be tested regularly beginning at about age 50, and that they should also subject themselves to the dreaded digital exam,” he said, adding: “I think most men are under the impression that PSA screening does lower mortality by allowing for early detection.”
It turns out it may be difficult for men to avoid prostate cancer screening, even when they want to. For years, Kramer, 59, had advised his own doctor that he didn’t want a PSA test. When he went for his annual physical last year, however, blood for a cholesterol test was automatically screened for prostate cancer as well.
“The result came back as a normal PSA without me knowing I’d had a PSA,” Kramer said. While some men might have felt relief at the results, Kramer said he knew better.
“The problem is, I know the evidence and there is no threshold of PSA that reassures people,” he said. “I know enough to say to myself that if I felt really reassured by that PSA, it was a false reassurance.”
Ron Viarengo said he hasn’t given much thought to prostate cancer since he decided against screening a few months ago. If researchers develop a precise test that can tell him whether he has cancer and what to do about it, fine.
“Otherwise, you can mess your brain around psychologically for no reason,” he said.
