By Dr Robin Roberts, Urology Consultant, Director, UWI School of Clinical Medicine & Research, The Bahamas
Despite the protest and outrage from physician organisations including the prominent American Urological Association and several US-based prostate cancer advocacy, education, and support organisations, the United States Preventive Services Task Force (USPSTF) released its findings last month, advising that healthy men should no longer take the PSA (Prostate Specific Antigen) blood test to detect prostate cancer as a routine or screening event.
The final conclusion and recommendation released to the media on Monday, May 21, 2012, said he ttest does more harm than good. The statement came as no surprise, and reinforced the Task Force's earlier draft statement issued in November 2011.
The Task Force's recommendation was national and its impact, immediate. On the day of its announcement, the statement was the evening news on all the national and local television and radio stations. The following morning, it was headlines in the print media as well.
Having led the charge over the past 20 years for Bahamian males to get their routine PSA testing, I am obligated and mandated to outline and define the issues of this PSA testing controversy and state my opinion as well. My position is clear: the Task Force's final recommendation is a backward step for us in the Bahamas. It is a major threat to the advances in the healthy lifestyle behaviors that we in the Cancer Society of the Bahamas have tried to inculcate in our male population over the past 15 years.
Why should we be concerned about The Task Force's recommendations on PSA testing in the Bahamas? The Task Force's interest had little focus on the African American population. Not surprisingly, men of African ancestry comprised only 15 percent of the American-based screening programme and none in the European.
While it acknowledged that men of African ancestry are at higher risk for prostate cancer, the Task Force maintains that the available evidence does not allow us to know with any certainty whether the balance of benefits and harms is different for men at increased risk. Like all who oppose the Task Force's conclusions, this is where I part ways with this particular issue too.
First and foremost, we must recognise that men of African ancestry have different prostate cancer biology. When we present with prostate cancer for the first time, in unscreened populations, we present with prostate cancer that is much more progressive - at least twice as advanced and we are up to four times more likely to die from it.
Research has also shown that prostate cancer in black men grows at a faster rate and is more likely to spread earlier compared to prostate cancer in the white male populations. When black men are diagnosed with cancer, at the same time of onset as their white counterparts and treated at the same time, our outcome with regard to living longer is the same, early or late.
However, if we are diagnosed at a later stage or if we delay treatment, our results are worse. We die earlier and suffer more from the devastation of this cancer. These are the facts.
Why is this? For black men, there is no doubt that the answer is somewhere in the genes. As a comparison, let's look at the research on breast cancer in the Bahamas; the evidence suggests that the genetic factors are reasons why breast cancer is so deadly in our female population.
There is a "bad gene" that can cause breast cancer and our Bahamian females inherit it. Dr Judith Hurley, a breast cancer specialist at the University of Miami School of Medicine and Dr Theodore Turnquest of the Oncology Center at the PMH reveal that breast cancer develops at an earlier age in the Bahamas with the average age of diagnosis in Bahamian women at 42 years, compared to 62 in the United States.
Moreover, 45 per cent of Bahamian women diagnosed with breast cancer are in the late stages of cancer, compared to 12 per cent of women diagnosed with breast cancer in the US. Dr John Lunn, Medical Director of the Bahamas Breast Cancer Initiative notes: "Bahamian women have the highest prevalence of this genetic (bad gene) mutation out of any population in the world, as 45% of women under 40 diagnosed with breast cancer have been found to have a BRCA1 (bad gene) mutation."
A woman without a mutation has a 13 percent chance of developing breast cancer; with one or more mutations, the risk jumps to between 36 percent and 85 percent.
It is of great interest that research evidence indicates a high association of the BRCA1 gene with prostate cancer as well.
Are Bahamian men transmitting the breast cancer genes to their daughters? The question is food for thought.
The Health Information and Research Unit database in the Ministry of Health cannot be ignored. In the Bahamas, 85 percent of the men are of African ancestry (probably higher with our interracial mix) and prostate cancer is the leading cause of death in men dying from cancer.
More importantly, my research over the past twenty years indicates that approximately 80 percent of the men who present with prostate cancer for the first time have advanced prostate cancer and they fall in the high risk group with a 50 percent risk of disease recurrence within five years.
Prior to PSA testing, our prostate cancer outcomes mirrored those of all other countries; this was a global phenomenon. Since the introduction of PSA testing however, what has become obvious is that in those countries that have undertaken routine annual testing and screening, there has been a major shift in first time presentations of the cancer - a complete reversal.
Now, in 80 percent of the men with cancers that are diagnosed early, the cancers are confined to the prostate and have the potential to be cured. The 40 percent decrease in death rates and 75 percent decrease in advanced disease presentations are evidence of the impact of PSA testing.
In developing countries, where men have not undertaken these healthy choices, this early occurrence - the stage migration of prostate cancer, has not occurred. Clearly this indicates that too many Bahamian men are not getting tested.
Unfortunately in the Bahamas, our Health Information and Research Unit of the Ministry of Health indicates also that the mortality rate for men dying from prostate cancer over the past 20 years has not decreased at all. Worst, the evidence indicates that our death rates have been increasing.
Currently, Bahamian men are not having regular PSA testing; the Task Force's recommendations can only make it worst. It is the wrong message to send our Bahamian males.
In addition to my own views and research, many urologists, support groups and I, are critical of the Task Force's statement and adamantly oppose their views, interpretations and conclusions. The responses discrediting the statements were immediate, furious, and distributed widely as well.
At the panel discussion of the AUA annual conference in May 2012, the urologist opinions were vehement: Many older urologists remember a time when they regularly saw men with advanced prostate cancer at their first urology consult. "It was as if people were drowning all around us," said Ian Thompson, MD, director of the Cancer Therapy and Research Center at the University of Texas Health Science Center at San Antonio, and chair of the AUA prostate cancer guideline panel.
When the PSA test came along in the 1980s, urologists saw it as a life preserver that could save patients' lives by detecting prostate cancer at an earlier stage. "Telling us to 'cease and desist' from offering PSA tests is just callous," said William Catalona, MD, professor of urology at the Feinberg School of Medicine, Northwestern University, in Chicago, Illinois.