To test or not be tested?That's the question, and Duke University physician Cary Robertson acknowledged, "it's a confusing one." The test is the PSA-based screening for prostate cancer. Prostate-specific antigen is a protein produced by cells of the prostate gland. The test, of the level of PSA in a man's blood, is used in conjunction with a digital rectal exam to determine whether there's prostate cancer. It's been recommended by federal officials since 1994 for men who previously had shown no signs of the cancer. Then, in May, the U.S. Preventive Services Task Force issued a new recommendation -- against PSA-based screening for prostate cancer. Michael LeFevre, a physician who co-chaired the task force, wrote that "there is a very small potential benefit and significant potential harms" from the screening process. Duke, said Judd Moul, director of the health system's prostate center, "does not necessarily agree with the task force." For the 24th consecutive year, Duke Med will be offering free prostate cancer screenings to men 40 and older, on Sept. 15 and 16. Duke physicians hope the new recommendation by the task force won't stop people from taking advantage of the opportunity. Robertson pointed out that the task force based its recommendation on a limited number of medical papers and "one of those papers, it could be argued, was premature." And "many organizations, if not most, concerned with this -- like the National Conference of Cancer Networks and the American Urological Association -- have come out against the task force's recommendation," Moul said. "The American Medical Association passed a resolution where they said the membership of the task force was not representative of American medicine. "We feel we should continue to test, with the caveat that patients are informed of the risks." The recommendation by the task force is particularly problematic, Moul added, because "a lot of men don't like to go to the doctor, and men have a higher chance of ignoring their health risks and they will use this [recommendation] as just an excuse to get out of it." Since there are no symptoms of early prostate cancer, getting a baseline screening at an early age can be extremely important, a number of Duke doctors said. "Men with a family history of the disease, with fathers, brothers or grandfathers who have had it, are at high risk," said Marva Mizell Price, an associate professor in the Duke School of Nursing. "Starting at age 40 these men need to sit down with a doctor and assess their risk factor. They need to at least discuss it and get a baseline test." The screenings, Robertson said, will detect at least 4 percent of common cancers. "If 150 men walk through the door when we do the screenings, about 10 of them we can probably help," he said. "Those men can get counseling. They can get treatment, if necessary. To not do it doesn't make sense. We're interested in saving lives." The free screenings, several doctors pointed out, are particularly important because of the population they serve, which includes many black men. Prostate cancer is the number-one cancer for males, said Mizell Price, and African American men are at markedly increased risk for it. According to figures from the Centers for Disease Control, the rate of prostate cancer for blacks is twice that of white men. The death rate is also twice as high nationally. And the rate for black men in North Carolina is among the highest in the country, Mizell Price added. In Durham, she said, those numbers are even higher. "This is a serious health issue for black men here," she said. "Very few places have a rate higher than Durham's." That's why the task force recommendation is so disturbing, Moul said. "For the task force to recommend against testing even for high-risk groups is throwing out the baby with the bathwater," he said. "They just made a blanket statement, and that's wrong." Most physicians recognize that the screening test probably has been overused in elderly men, Moul acknowledged, and "perhaps we have treated some very early stage cancers perhaps too aggressively. Perhaps we have over-treated more men than we should have." Physicians today, Robertson agreed, "need to be more measured in our response." But "active surveillance" after the test, much more common now, "is a very reasonable way to follow patients. We're following without aggressive treatment." And it's clear screening has worked, Mizell Price said. "With screening, we've seen a 10-fold decline in rates of metastatic disease. I really don't want to go back to the pre-PSA era." Although some physicians are reporting a slight decline in the number of men coming in for screenings from their primary physicians, the Duke doctors actually hope the controversy will end up increasing awareness and even encourage more men to come in and be tested. "This is life-saving," Mizell Price said. "Absolutely life-saving."
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