The PSA stormBMJ 2002; 324 doi: http://dx.doi.org/10.1136/bmj.324.7334.431 (Published 16 February 2002) Cite this as: BMJ 2002;324:431
Questioning cancer screening can be a risky business in America
Many people in the United States think that screening is a panacea, a way of warding off disease and staying healthy—perhaps forever. Those who question this fairytale view, as we recently discovered, are considered traitors, or even murderers.
On 18 December 2001, the San Francisco Chronicle published an article in its sports section about Dusty Baker, manager of the Giants, the city's baseball team. Baker had just had surgery for prostate cancer, which was diagnosed after a “routine” blood test for prostate specific antigen (PSA).
A urologist was quoted as saying that PSA tests had made “a world of difference” in fighting prostate cancer because “doctors have been able to catch the tumors early before they have spread.” Baker's doctors had chosen surgery over other treatments, said the article, since surgery was “the surest way to prevent any return of the disease.”
Thousands of men would have seen this article and it would have left them with an extremely optimistic picture of the benefits of PSA testing and of prostate surgery.
We wrote to the Chronicle arguing that the newspaper had failed to reflect the massive controversy surrounding prostate cancer screening. The Chronicle's editorial team knew nothing about the controversy, which is no surprise given the dominance of the US media by the pro-screening lobby.
The editors invited us to write an opinion piece discussing the reasons why men should not be screened. The piece appeared on 18 January 2002, in a section devoted to personal views and debates.
We argued that the PSA test was unreliable, that it often picked up innocuous tumours, and that picking up such tumours harmed men by causing anxiety and by subjecting them to unnecessary cancer treatments with serious side effects.
A programme to screen healthy men, we said, could not be justified since there was no good evidence that it would change the outcome of the disease. The US Preventive Services Taskforce, we told readers, did not recommend screening for prostate cancer.
Within hours of our piece being published, prostate cancer charities, support groups, and urologists around the country had circulated a “Special Alert” by email. This community has huge faith in PSA tests, and it did not care for our opinion. The email, under the header “ATTENTION MEN!!” urged the community to take action.
By the end of the day, our email inboxes were jammed with accusations, abuse, and threats. We were compared to Mengele, and accused of having the future deaths of hundreds of thousands of men on our hands.
Our view, said one letter, was “geriatricide in the making.” The president of a prostate cancer charity said he would be asking “supporters and legislators” to look into our “behavior.” Many people wished that we ourselves would get prostate cancer. Others tore apart our credentials, arguing that only urologists were qualified to talk about PSA testing.
A member of a prostate cancer email group advised other members to take two actions. First, he said, put “continued pressure on the San Francisco Chronicle” to publish material that would “offset the damage” we had done. The Chronicle was bombarded with angry phone calls and emails, and says it has never published a more controversial piece.
Second, he said, “Write to their [the authors’] bosses at University of California Davis and the Office of the President. Tell them to fire these imposters. Tell them these folks should be silenced.” The chancellor of the University of California and the dean at University of California Davis medical school have received a flood of letters urging that we are disciplined or fired.
By coincidence, in the week after our piece was published, the United States heard the dramatic news that the benefits of mammography were under debate (see p 432). Suddenly Americans were facing some difficult questions about screening.
“The uncomfortable fact is,” said the Chronicle (3 February 2002), “despite … the incessant drumbeat telling women to get yearly mammograms and men to get their PSA test, screening for breast and prostate cancer is far from perfect and the decisions are not entirely clear-cut.”
The paper was unapologetic about publishing our piece. On 4 February, it pondered the backlash against us: “Amid the frustration, the anger and the vitriol, there is no ignoring the controversy.” It published an editorial by a urologist arguing the merits of the PSA test, and another by us discussing the risks.
Why did we experience this fierce backlash?
One reason is that the PSA advocacy group is passionate in its belief that routine testing is good for men's health. It wishes to believe that screening really does make “a world of difference.” We angered this group by challenging its wishful thinking.
We also stepped on the toes of a very wealthy and powerful pro-screening lobby that stands to make money from encouraging men to get tested. Even some of the patient support groups in this lobby have a conflict of interest, since they rely on pharmaceutical company support.
With the widespread belief in America that every man should know his PSA, a belief driven by politics and not evidence, we fear that sceptical voices like ours will always be drowned out.
Competing interests The authors have received a grant from the Centers for Disease Control to devise a teaching tool for primary care physicians on prostate cancer screening.