The PSA test is used to help to determine if a man has prostatic cancer or not. If the PSA is high and/or rising, then doctors have argued to me that this signifies a higher risk of cancer.
Like many men in their sixties, I was advised by my GP to have a PSA test. He is a good bloke and I complied. It was “high”. I was referred to a urologist who recommended a biopsy which would give a better indication if cancer were present or not.
So I asked, given the level of my PSA, what the probability was that I had cancer; if I had, what the probability of death was without treatment and what it was with treatment. He responded: “I don’t deal in probabilities!” I then asked (he thought rhetorically!): “How can I make an informed decision?”
I gave up.
Then about a year later, I stupidly had another PSA test. It was “high” so I saw another urologist … it was again suggested I have a biopsy. I had one and I was clear.
Then when recently I asked my GP for an overall health check (as I want to run a marathon this year), he included a PSA test. It was “high” — everything else was fine. So back to see the second urologist again. Advice? Have a biopsy.
Again my response: what are the probabilities? Doesn’t know but in my presence rings a urologist colleague “who is one of these chaps who has all the numbers”. Explains over the phone “I have this patient who is a scientist like us and wants to know the stats.”
But that urologist was going on holiday for four weeks…
So what do I do?
I have been to the Cochrane website (screening for prostate cancer), the cathedral of evidence based medicine. It states on PSA testing:
Given that only two randomised controlled trials [have been conducted], and the high risk of bias of both trials, there is insufficient evidence to either support or refute the routine use of mass, selective or opportunistic screening compared to no screening for reducing prostate cancer mortality.
So maybe I didn’t get the probabilities because they don’t exist?
The Cancer Council Australia states:
Men at above-average risk of prostate cancer should … be given adequate objective information about the potential benefits and harms of screening, diagnostic procedures and treatment for prostate cancer to allow them to make a fully informed decision on whether to be tested or not.
So why do I and I presume so many other men have such difficulties in getting “adequate objective information”?
Being told that the results of a test suggest a higher chance of cancer does stimulate anxiety in the man concerned and in his nearest and dearest. I know. More PSA tests and biopsies also mean more fees for doctors. In a health service strapped for cash, do we really need so many of these PSA — Potentially Stimulating Anxiety — tests?
And as a footnote: having coffee with a colleague of my same age group last week, I mentioned all of this to him. His response? “I would never think to question my doctor. I would just trust him and have the biopsy.”
But can we trust our fee-for-service doctors to do the right thing — and not more — when there is a fee attached?