Prostate Screening, an Important, Imperfect Tool

By joyfotoliakid @Adobe Stock

In Spectator.com, Dr. Steven Quay has a question. It’s not rhetorical, he notes. Rather, it’s a clinical question: Why wasn’t Joe Biden screened for prostate cancer beyond 2014? A routine prostate-specific antigen screening seems to have been Biden’s last.

The diagnosis of Biden’s cancer is a tragedy, and every American ought to pray for the best outcome possible, implores NRO’s Jim Geraghty.

But instead of quieting the controversy about Biden’s health and the effects of aging in his final years in the White House, Sunday afternoon’s announcement of the diagnosis will justifiably intensify the questions about who knew what and when about Biden’s health.

Could It Be Malpractice

The standard blood test (PSA) for prostate screening has been around for 30 years. Yes, an elevated PSA can be a marker for cancer, but it also can signal a false positive or an inactive cancer.

What could be the downside of discovering a false positive marker or an inactive cancer? A biopsy might be the recommended next step, and that biopsy is generally considered painful. More worrisome, it can lead to overtreatment with punishing side effects, such as impotence, incontinence, and bowel dysfunction.

To ignore PSA testing in someone healthy and high functioning may not be malpractice in the courtroom sense. On the other hand, it could be considered a missed opportunity for preventive care, especially considering that prostate cancer remains the second leading cause of cancer death in American men.

Dr. Alicia Morgans, a genitourinary medical oncologist at the Dana-Farber Cancer Institute in Boston, recognizes the problem and hopes that the task force will address it in new guidelines.

Dr. Morgans told NPR that she believes the current guidance is based on a flawed clinical trial.

… men screened with PSA tests were no less likely to die of prostate cancer than men assigned to a group that was not screened. However, the results were muddied because nearly 90% of the men in the control group had at least one PSA test before or during the trial, she said.

A final PSA in 2014 for Vice President Biden might have been clinically justifiable as a stopping point.

But given his exceptional health, life expectancy, and continued national leadership, there’s a strong argument it should not have been his last.

Let’s say Biden had aggressive prostate cancer brewing beneath the surface, one that wouldn’t show symptoms until it had metastasized. By 2020, he would have been 78 and leading a nation through a pandemic. By then, treatment options could be limited. A timely PSA could have changed that trajectory.

Dr. Steven Quay asks (and answers) three consequential questions:

• Would screening have saved Biden’s life? “Perhaps.”
• Would it have spared suffering or complexity? “Likely.”
• Would it have fit within the AUA guidelines? “Absolutely.”

Data from lower-risk prostate cancer suggests that it is safe for patients with slow-growing cancers to be carefully monitored instead of rushing into treatment. That would help reduce the risk of harm. PSA testing is not the only test.  A prostate MRI and biomarkers can now help cut down on false positives. Medicine isn’t about treating age; it’s about treating people, continues Dr. Quay.

Guidelines help us draw lines, but great clinicians know when to blur those lines for the right reasons.

Given Joe Biden’s exceptional health and vitality, coupled with the data, Dr. Quay notes, there is a strong argument that 2014 should not have been his last screening.