By: Dr. Brent Schillinger, Guest Contributor
In the broadcast and print media world PSA stands for public service announcement. In medicine PSA stands for prostate specific antigen. Along comes comedian/actor Ben Stiller who basically releases a public service announcement urging men to be tested for elevated levels of prostate specific antigen. This all sounds well and good but since the release of Stiller’s announcement live on the Howard Stern Sirius radio show in early October, there has been nothing but controversy.
So why the controversy? Stiller was tested and treated back in 2014 while he was still in his forties. His message today is loud and clear “The prostate cancer test that saved my life.” The problem is that a number of highly reputable and credible groups have actually recommended against what Stiller did. The USPSTF (US Preventative Services Task Force) doesn’t think anyone should be screened for PSA levels and gives the test a “D” rating. The American Urological Association says for men under 55, only high-risk patients should be tested. The American Cancer Society is a bit less dogmatic suggesting that men at average risk begin the conversation about PSA testing with their physician at age 50. The challenge with the PSA test is its lack of specificity. This leads to a substantial number of cases of over-diagnosis and over-treatment, which all too often presents a whole new set of complications including impotence and incontinence.
In Stiller’s case his doctor offered to give him a baseline PSA test when he was 46. The PSA level was elevated and he continued to monitor the situation with a new PSA every six months for the next year and a half. When the levels continued to rise his internist referred him to a urologist. The urologist performed an old fashioned digital exam and felt something he wasn’t comfortable with. Next he ordered an MRI and told Stiller this was most likely cancer. A subsequent biopsy revealed he had a mid-range Gleason 7 aggressive cancer. The next recommended step was robotic assisted laparoscopic radical prostatectomy. This procedure removed the tumor successfully as Stiller has been deemed cancer free now two years later and he isn’t complaining of any post treatment complications
In medical ethics we talk about certain key concepts. One is autonomy, the patients right to make an informed decision. Another concept is beneficence, doing good for the patient. And then there is non-maleficence, basically to do no harm to the patient. In the real world enthusiastic doctors are prone to recommend treatments
that they believe will do good without first having evaluated them adequately to ensure they do no harm, exemplified in the saying “The treatment was a success but the patient died.” The PSA issue brings into focus the difficult challenge in balancing good against harm. Ultimately a patient will have to choose, but based on what information? Should Ben Stiller have more influence than the American Cancer Society?
As per the headlines, it would seem that Stiller is a high profile celebrity endorsing PSA testing to save a man’s life. This celebrity factor makes it that much more confusing for the average consumer. Ben Stiller seems like a good guy. Smart, funny, and if it’s good enough for Ben why not for me? But if you read his post verbatim, Stiller asserts “I think 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. After that an informed patient can make responsible choices as to how to proceed.” So he is not actually endorsing PSA testing per se, but merely suggesting that all men have an open discussion with their physicians on the topic. In that context I don’t see much to argue over. Perhaps the bigger issue is an overzealous media that is trying to make controversy (through headlines) where none exists. Yes PSA testing is controversial but having a discussion with your trusted doctor on that very topic should not be a controversy.