Dr. Scott Miller on CNN Discussing PSA Testing Controversy

Dr. Scott Miller discusses the common sense view of PSA blood test screening for prostate cancer on the Sanjay Gupta Show. Dr. Otis Brawley presents a somewhat opposing view.

Dr. Gupta:  A lot of people are asking questions and today I’m going to try and answer some of the bigger ones. What you need to know first of all about that flesh eating bacteria. Also, why one in three schools have air quality so bad it can make children sick, what to do about it.  And what is the filthiest spot with the most germs in your workplace. We’re going to get to those but first lets take a look under the microscope.

You know we are looking at this controversial new position from the US Preventative Service Task Force, which says men should not be screened routinely with a PSA test. As you probably know by now it’s a simple blood test and it’s the only screening test for prostate cancer. Which is the second leading cause of cancer deaths in men. Now the American Cancer Society supports these new guidelines but many other groups do not.

So I’m here today with Dr. Otis Brawley, you know him from the American Cancer Society also Dr. Scott Miller a urologist who says not screening could cost lives. We’re going to get to that debate in just a moment but first I want to try and explain some of the reasoning behind these new recommendations. Basically they say that more people could end up harmed by unneeded treatment after a worrisome PSA result than are saved by early detection. Now we talked about these numbers a lot but its not an abstract problem, I want to bring in Dr. Jeffery Stark. He is a pediatrician in Houston who last year became a prostate cancer patient himself. Welcome Dr. Stark thanks for joining us. You know as I said there are real stories behind a lot of these numbers you are concerned as many men are about prostate cancer. You had a family history, you wanted to get it checked out so what happened after that?

Dr. Starke: Well, several years ago I had a slight rise in my PSA from screening and I had a biopsy done then which showed everything was ok. I had more testing done after that and had again a very slight rise in my PSA and the urologist wanted to do another biopsy. Which I had done a year ago February and I got extremely sick. Even though I had antibiotics I got septic.

A severe bacterial infection with high fever, shaking, chills, my blood pressure went dangerously low. My circulation shut down and I was hospitalized for four days here in Houston.

Dr. Gupta: And you’re OK now, Obviously that all resolved?

Dr. Starke: Yeah, I’m fine. Actually I had a little heart rhythm problem afterwards as well but everything is fine. I don’t have prostate cancer.

Dr. Gupta: I wanna get back to you in a second Dr. Starke but Dr. Miller you hear a story like this and obviously this is one case there are lots of different cases. But what do you think as a urologist when you hear something like this. He got harmed potentially by this. By going through the biopsy, getting the infection, his heart problem. Did not have prostate cancer, how big of a concern is that to you.

Dr. Miller: Well it’s a big concern, I’m very concerned. I sympathize with Dr. Starke’s position, his perspective on it and I am happy that he is fully recovered and happy that he doesn’t have prostate cancer. But that is a complication of the biopsy. What the task force has put forward is that would be a result, that these types of complications would be a result of the PSA blood testing, but its clearly a complication of the biopsy.

Dr. Gupta: What do you tell your patients? In terms, at the beginning of the whole process. Somebody comes in they say “ We’re gonna get a PSA blood test” how do you talk them through how that whole scenario could go for them?

Dr. Miller: Well, the first thing I tell them is what the PSA is for, its to screen for prostate cancer its not to diagnose prostate cancer. We need other test to diagnose prostate cancer. The PSA blood test can vary depending on the patients situation. So depending on whether they’re old , young , what their risks factors are for prostate cancer will be one factor in terms of my recommending a biopsy subsequently.

Dr. Gupta: Dr. Brawley, obviously, your position in this is you’ve written about this and talked about this quite a bit, and the American Cancer Society supports these new guidelines. What do you think the role of PSA testing is? Sounds like people want to abolish it nearly completely.

Dr. Brawley: We need to move screening into the physician patient relationship.

Where physicians look at a particular patient and say “These are the known harms, these are the possible benefits. There are a lot of harms associated with it but there may be some benefits, do you want to get screened? “  And let the patient decide.

Dr. Gupta: But look I’m a doctor and have a hard time answering that question I’ve read all these studies, How’s a patient supposed to make that decision?

Dr. Brawley: Well I think the most important thing is there’s been so much -you should get a prostate cancer screening- without actually explaining to people that there are harms out there.

Dr. Gupta: So what would you say to them? I asked Dr. Miller the same question. So lets say I’m getting a test in your office. I know you’re not a urologist but lets just say I am. What would you tell me?

Dr. Brawley: Well actually I do practice general internal medicine. I do think that there’s is a point in time where the patient can legitimally say ” Doc, I cant make a decision can you help me or make the decision for me?” And I think the doctor should weigh the patients concerns, the patients risk factors also inform the patient that we don’t really have good studies to show that this saves lives.

Dr. Miller: Well I disagree I think there is evidence in several studies that does save deaths. I’m not gonna quote these statistics but there has been a forty percent reduction in prostate cancer deaths since the advent of PSA.

Dr. Gupta: I’ve heard you say “Look if you have symptoms you should get tested” What are symptoms?

Dr. Brawley: Yeah, any man who has urinary problems like benign prostatic hyperplasia, I thin its very reasonable to do the test there.

Dr. Gupta: But most people develop that.

Dr. Brawley: And it may be reasonable to do a test.

Dr. Gupta: I don’t mean to keep interrupting you. So, if you say symptoms are some of these urinary symptoms and most men will develop it aren’t you just testing them now late?

Dr. Brawley: Not necessarily, indeed there’s some studies that suggest that that is not he case. That you can still have early detection when using the test.

Dr. Gupta: And I bring it up because again, these are conversations that men have and say “Look I’m going to develop the symptoms which would lead to PSA testing”  So you’re just saying wait till I get it wait till I’m more advanced in age. And that could potentially be also letting cancer run a month. But let Dr. Miller weigh in. What are you gonna do now? How does that effect your practice?

Dr. Miller: May I respond to the symptom question?

Dr. Gupta: Yeah

Dr. Miller: I actually disagree, I do think that patients who have symptoms need to be evaluated for many reasons and probably including the PSA blood test. But number one prostate cancer often is not curable once you have symptoms from the prostate cancer.

Dr. Brawley: Keep in mind all of us agree, I think you will agree with this, that men who are over the age of fifty especially should know the known harms associated with PSA screening and treatment. Its really not the screening is the treatment associated with the screening that causes the harms along with the potential benefits.

Dr. Gupta: Dr. Starke you’ve been listening into this conversation. Look, I mean would you do it again? Given all that you know now and all that you just heard.

Dr. Starke: I teach residents and students and reinforce the principal that I teach them and that is when a person without significant risk factors is screened with any kind of test ,a positive result is actually more likely to be a false positive and if that false positive leads to an invasive treatment or procedure being done it can lead to consequences and unfortunately in my case those consequences occurred.

Dr. Gupta: Well I’m glad you’re doing well Dr. Starke. I hope we tried to make of this a little bit clearer for people out there. It is confusing but as I was saying to Dr. Brawley and Dr. Miller, ahead of time, its fun to dive into these issues every now and then. Thanks for joining us.

Dr. Miller: Thank you for the opportunity.

Dr. Brawley: Thank you.

Dr. Gupta: We’ll keep talking about it I think.