Beyond Ben Stiller’s advice: What the experts say about PSA screening

Comedic actor Ben Stiller revealed this week that in 2014, he went through treatment for prostate cancer, referring to the PSA test his doctor gave him at age 46 as the “prostate cancer test that saved my life.”

His essay, reminiscent of Angelina Jolie’s New York Times opinion pieces regarding her own health issues, spoke of the shellshock, confusion and the rapid learning curve he experienced upon diagnosis:  “One of my key learnings,” he wrote, “is not to Google ‘people who died of prostate cancer’ immediately after being diagnosed with prostate cancer.”

But the bulk of the piece addressed what has become a scientific sticky wicket: screening recommendations.

“If [my doctor] had waited [to get me a PSA test], as the American Cancer Society recommends, until I was 50,” Stiller wrote, “I would not have known I had a growing tumor until two years after I got treated. If he had followed the U.S. Preventive Services Task Force guidelines, I would have never gotten tested at all, and not have known I had cancer until it was way too late to treat successfully.”

The reaction to Stiller’s piece was swift and sundry. Some praised the actor for advocating on the behalf of men everywhere; others referred to his advice as misguided and unscientific. Mostly, it raised questions. Are you confused about what you should do – or who you should believe – following this latest piece of celebrity screening advice? We tapped two experts from Fred Hutchinson Cancer Research Center to help sort it out. 

What do current prostate cancer screening guidelines say?

First, screening guidelines are issued by various organizations and each has its own take.

The latest guidelines from the U.S. Preventive Services Task Force, issued in 2012, recommend that men without symptoms receive no prostate-specific antigen, or PSA test, at any age. The American Cancer Society guidelines, issued in 2010, recommend average-risk men have a discussion with their doctor about whether screening is right for them starting at age 50. High risk men should start having that discussion at 45. Those with multiple first-degree relatives with prostate cancer are advised to have the screening talk starting at age 40. After that discussion, they should decide whether they want to be screened and should not be screened unless they have that discussion. The American Urological Association’s 2013 guidelines drill down a little deeper, recommending that average-risk men between the ages of 55 and 69; men under 55 who are at high risk (i.e., they’re African American or have a family history of the disease); and healthy men over the age of 70 all talk to their doctors about screening with no PSA tests recommended for asymptomatic men outside those ranges.

Dr. Ruth Etzioni, a Fred Hutch biostatistician whose research specifically focuses on the effectiveness of screening for both prostate and breast cancers, acknowledged that multiple recommendations can make it “very confusing for the public” but said it helps to keep in mind the mission of each organization. The Task Force is made of primary care doctors and thus, is more concerned with a whole healthy population, while the American Cancer Society is all about reducing deaths from cancer so their guidelines may be more rigorous. 

What do our experts recommend?

Dr. Pete Nelson, a clinical researcher and prostate cancer oncologist at Fred Hutch and its treatment arm Seattle Cancer Care Alliance, said both the American Urological Association and the American Cancer Society guidelines seem reasonable.

“I suggest all men get screened or at least get a baseline at 50,” he went on. “If there’s any family history of prostate, breast, ovarian, and pancreatic, they may want to get screened earlier. And if they’re African American, they should certainly get that baseline at 40 or 45 as well as participate in studies.”

Etzioni sympathized with Stiller, who said he believed “men over the age of 40 should have the opportunity to discuss the test with their doctor and learn about it so they can have the chance to be screened.”  

But, she said, screening guidelines are designed for the masses, not the outliers.

“Indeed, there are men who are young and who get bad prostate cancer and it really is a terrible thing,” she said. “The issue is this happens very rarely among white men without any family history.

“The thing that people have to realize about screening is this: screening cannot save everyone,” she said. “If we screen to save everyone we would have to screen so early and so often that it would not be reasonable from a cost and a morbidity perspective. The issue with screening is ‘How do we save the most lives in a manner that is acceptable from a population health perspective?’ I’m afraid that screening all men in their 40s is not going to satisfy this. It is a needle in a haystack situation. Making screening policy means making really difficult decisions because inevitably you will not be able to screen in a way that saves everyone.”

Etzioni co-authored the AUA guidelines "so (does) like them better than USPSTF."

Why is there such back and forth about prostate screening?

Why is there such a controversy about when men get screened? It’s all about balancing the harms (false positives, overtreatment and complications) with the benefits (finding and treating aggressive cancers early).

“Cancer is so common in the prostate, if you go looking for it, you’ll more than likely find it,” said Nelson. “But not all prostate cancers are created equal.”

Nelson said a large subset of cancers are indolent; they’re slow moving and will never cause harm. Another subset behaves very aggressively and may progress so rapidly that even surgery and radiation won’t be able to help; the cancer will spread and the patient will eventually die. Another subset, he said, is destined to spread but if caught early, can be treated and cured.

“That’s where the benefit of screening comes in,” he said. “You’re detecting cancers that would be lethal at the point when they’re still curable. But the screening tests don’t distinguish. You need a biopsy to distinguish what’s indolent or aggressive.”

So why not just screen all men?

Nelson said the Task Force guidelines used to recommend a more liberal approach to screening but further research demonstrated many men were being tested, diagnosed and then treated for cancers that weren’t aggressive. So the guidelines were revamped.

“They were being overtreated,” he said. “These men with low grade, low volume indolent-appearing cancers were being treated with radical treatments like surgery and radiation. There’s been a sea change since then and there’s no question that they changed it for the better.”

Etzioni said the Task Force’s 2012 guidelines concluded screening was so ineffective – and treatment so morbid – that “there’s was no way to make it acceptable from a population health perspective.”

“There’s no question that we need a better test,” said Nelson. “A PSA test has a lot of vagaries. The bottom line is we need better markers and a better screening test, ideally one that would only identify the aggressive cancers.”

Nelson is currently working on finding both.

“We’re trying to identify genetic risks in the urine that would associate with the more aggressive prostate cancers,” he said. “And also blood-based [screening] tests. We’re also following men to show that you don’t have to treat prostate cancer right when it’s diagnosed. You can safely watch these cancers over time and catch them at a point where they appear to be more aggressive.”

What should men keep in mind?

Nelson said the biggest issue is not when men are screened, but whether men who are screened and subsequently diagnosed should go through treatment.

“I don’t recommend they automatically get treated,” he said. “That’s the big distinction. Determining they have a cancer by biopsy is key, but they don’t automatically have to have treatment. Active surveillance is becoming more accepted now and urologists are becoming better at describing it to patients. They’re not saying, ‘Don’t do anything ever.’ They’re saying, ‘Don’t do anything now.’”

Stiller's doctor used what Etzioni called "close monitoring," with his patient, a nuanced approach that monitors the PSA situation without rushing towards biopsy. Necessary for diagnosis, biopsies are also invasive and can cause complications like infection which can lead to hospitalizations and even death, though rare.

“My doctor … watched my PSA tests rise for over a year and a half, testing me every six months,” Stiller wrote. “As the numbers continued to rise, he sent me to the urologist, who gave me a slightly invasive physical check in his office using a gloved finger. This took all of 10 seconds … After this exam, and looking at my rising PSA numbers, he suggested an MRI to get a roadmap of my prostate.”

After his MRI, Stiller’s doctor recommended a biopsy. The biopsy came back positive for cancer.

“The key,” Nelson said, “is finding the sweet spot for not overtreating and not undertreating the population. That’s why PSA screening is still very reasonable. And obtaining a biopsy is still very reasonable. When there’s a decision point, that’s where discussion needs to occur with a specialist who will say, ‘You need treatment’ or ‘We need to watch this.’ For most men, they need to watch it.”

Are there new guidelines on the horizon?

According to the Task Force, new guidelines are in the process of being created.

“As with all of its recommendations, the Task Force reviews evidence on the benefits and harms of preventive services that apply to patients without symptoms or signs of the disease,” it said in an emailed statement. “When the Task Force last reviewed the evidence on prostate cancer screening in 2012, evidence showed that there is a small potential benefit to screening for prostate cancer and there are significant known harms. As such, the Task Force recommended against routine screening of all asymptomatic men at average risk for prostate cancer.

“However,” they added, “the Task Force encourages any man who is concerned about his risk of prostate cancer to talk to his doctor about whether screening is appropriate. This recommendation does not preclude a man choosing to be screened."