A year ago, Rabbi Jon Adland underwent genetic testing and discovered that he was positive for mutations on both BRCA1 and BRCA2 — the so-called breast cancer genes that raise the risk for breast and ovarian cancer, especially in Ashkenazi Jews, who are over 10 times more likely to have a BRCA mutation than those in the general population.
“I went in thinking, Oh, I’m going to be fine, but I came out with both. Not every man gets to hit a home run,” said Adland, 58, who is the rabbi of Temple Israel in Canton, Ohio.
Adland decided to get tested after several family members were diagnosed with breast and ovarian cancers. What he did not realize was that BRCA also has been linked to prostate cancer risks. “I learned about it when I went in for genetic counseling. It was a bit of a surprise to me,” he said. The counselor and his physician therefore advised Adland to regularly get a PSA test, a blood test that measures a protein in the blood produced by cells where most prostate cancers begin.
Ever since the PSA, or prostate-specific antigen, test was first used in the mid-1980s, it has become the gold standard of prostate cancer screening, with most guidelines suggesting that men be screened once a year, starting at age 50 or somewhat earlier, if they are at elevated risk for the disease. But recent controversy surrounding the PSA test has left many wondering what men like Adland should be doing to monitor their prostates.
Last May, the government-backed U.S. Preventive Services Task Force released guidelines recommending that physicians stop using the PSA test to screen for prostate cancer. The Task Force, an advisory board of independent medical experts, came to this conclusion based on a review of two major screening trials of men — one in Europe and one in the United States.
After skin cancer, prostate cancer is the second most common cancer among men in the U.S. and the second leading cause of cancer deaths worldwide, after lung cancer. Yet, when caught early, prostate cancer usually has a good prognosis.
As a screening tool, however, the PSA test has some significant flaws. Prostate cancer often grows at such a slow rate that, depending on his age and health, a man diagnosed with the disease may have a good chance of dying from other causes before the cancer can cause any harm. Further complicating the picture is the fact that as men age their prostates often become enlarged and produce more PSA, even if the growth is benign. False positives have increased in recent years, as the cut-off level for a supposedly worrisome PSA number has dropped.
Finally, further diagnosis and treatment can have considerable side effects. As many as one third of men who had biopsies for abnormal test results, according to the Task Force, experienced pain, fever, bleeding, infection or transient urinary difficulties. Treatment for the cancer itself is even more fraught with complications, including erectile dysfunction, impotence, urinary incontinence and, in rare instances, heart attack or stroke.
As a consequence, controversy has swirled around the PSA test for some time now, with critics talking of over-diagnosis and over-treatment. “It was the assessment of the Task Force that the potential benefits from prostate cancer screening do not outweigh the harms,” said Dr. Michael LeFevre, director of clinical services at the University of Missouri’s School of Medicine and co-vice chair of the Task Force. “The treatments cause harm in greater numbers of men who have a disease that would never have hurt them in their lifetime.”
The Task Force’s guidelines ignited debate and criticism. While many in the medical community agree with its critique of how the PSA test has come to be used, others believe their recommendations went too far.