Know the history behind the use of PSA tests for the prostate
DEAR DR. ROACH: I read your recent column concerning the fellow who was reluctant to go to a doctor regarding his prostate. I'm very curious why the PSA is now considered a legitimate test for prostate problems. I distinctly recall a discussion on the radio with a doctor about 25 or 30 years ago, in which it was carefully explained why the PSA is of little value and is not worth doing. Do you remember that time? I'm wondering if it was the insurance companies that were behind that policy. -- F.B.
ANSWER: I remember that time very well. The change does not have to do with insurance companies, but through a better understanding of how best to manage low-risk prostate cancer. Most prostate cancer found at screening (meaning men with no symptoms) is low-risk. Many times, both men and their physicians insisted on definitive treatment for even low-risk prostate cancer when it was found through screening. That meant many men getting surgery, with its attendant high risks of sexual dysfunction and urinary incontinence, as well as a small risk of life-threatening complications.
A review of the risks and benefits for prostate cancer screening as a whole found that the risks (including the many men who got complications) outweighed the benefits, and some (but not all) experts recommended against prostate cancer screening. While this prevented many complications from surgery, it also had the effect of preventing many men from being screened and, therefore, coming to medical attention only when the prostate cancer was advanced and no longer curable. We weren't harming the low-risk men, but we weren't helping the high-risk men either.
The current recommendation attempts to maximize the beneficial effects of screening while minimizing the harmful outcomes of performing surgery in men in whom it is not really necessary. Currently, men are recommended for a screening through a PSA test. If this is abnormal, a careful evaluation often includes an imaging study of the prostate (such as an MRI scan) and an imaging-guided biopsy. We have a better way of stratifying risk so that many men can safely defer surgery through the process of active surveillance. If men have low-risk prostate cancer, they undergo regular follow-up evaluations to make sure the cancer is behaving in an indolent fashion; if not, it will be treated aggressively.
Fewer unnecessary surgeries mean less side effects. Surgery and other treatments are reserved for the men who are most likely to benefit, so (hopefully) the majority of men with curable cancer found during screening can get effective treatment, while the much-more-common situation of low-risk prostate cancer will not cause a man to undergo unnecessary risk.
DEAR DR. ROACH: Which brand of glucosamine/chondroitin do you recommend? -- R.E.
ANSWER: I don't recommend glucosamine/chondroitin, since there is no strong evidence to prove it is better than a placebo, although I have had patients (and many readers) who swear it is effective for them. Since it is safe and not expensive, I do recommend my patients to continue it if it seems to be helping.
I don't recommend any particular brand names. Whenever possible, I recommend purchasing supplements that have been independently analyzed by a third party, such as USP. I did find glucosamine/chondroitin supplements available in a major online retail store that are certified.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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