Ben Stiller's Essay About Prostate Cancer Is Moving But Not Scientific
He credits a controversial screening test ― the prostate-specific antigen, or PSA, test ― with saving his life:
Taking the PSA test saved my life. Literally. That’s why I am writing this now. There has been a lot of controversy over the test in the last few years. Articles and op-eds on whether it is safe, studies that seem to be interpreted in many different ways, and debates about whether men should take it all. I am not offering a scientific point of view here, just a personal one, based on my experience. The bottom line for me: I was lucky enough to have a doctor who gave me what they call a “baseline” PSA test when I was about 46. I have no history of prostate cancer in my family and I am not in the high-risk group, being neither ― to the best of my knowledge ― of African or Scandinavian ancestry. I had no symptoms.
Counterintuitively, while Stiller believes that he saved his own life by getting a PSA test early, his example goes against medical recommendations that are in place to protect men from unnecessary treatment and serious, potentially life-threatening side effects that can come from treating a cancer that probably won’t kill them.
And that’s the catch: Prostate cancer is often so slow-growing as to never be fatal. The majority of evidence shows that most men with prostate cancer will not die of their disease, regardless of whether they were diagnosed, received treatment or are monitored carefully. Indeed, the five-year survival rate for prostate cancer is almost 100 percent, and the 15-year survival rate is 95 percent.
This means that the 26,000 men who will die from prostate cancer in the U.S. this year likely would not have been helped by routine, asymptomatic PSA screening, explains Dr. Otis Brawley, chief medical officer of the American Cancer Society.
“The harsh truth is that even under the best conditions, with careful screening, some men will still die of prostate cancer,” Brawley said in a statement. “This is why no major health group recommends all men be screened. The PSA test can be useful, but it is not perfect, by a long shot.”
More testing does not mean more lives saved
The prostate produces PSA normally, and levels can become elevated because of a cancerous growth. Increased PSA is the first clue doctors normally have that an asymptomatic patient may have a problem. However, PSA levels can also become elevated because of infection or the natural process of aging ― not cancer.
For this reason, while high PSA readings might lead doctors to find aggressive, spreading cancer, it can also lead to unnecessary surgery or other cancer treatment for a tumor that either doesn’t exist, or is so slow growing that it wouldn’t otherwise be deadly.
Unnecessary surgery and treatment is harmful ― and can even be deadly ― because procedures can introduce medical complications that men may not have otherwise faced if they hadn’t treated the cancer in the first place. These complications can include bowel and urinary incontinence, sexual dysfunction and life-threatening cardiovascular issues.
And just because a man is diagnosed with prostate cancer, that doesn’t necessarily mean he should be treated for it. A study recently published in the New England Journal of Medicine found that almost half of the men who decided to take a “watch and wait” approach to prostate cancer, opting for active surveillance over radiation or surgery, didn’t need any additional treatment over the course of 10 years. This means that they were able to avoid the potentially dangerous side effects of treatment, all the while being secure that they had identified a potential problem and were being proactive about it.
Indeed, this is already happening in the U.S.: About 50 percent of men who get diagnosed with prostate cancer now opt for active monitoring over aggressive treatment.
Why health experts no longer recommend the PSA test
Because the PSA test has a risk of false positives and over-diagnoses (some trials estimate the over-diagnosis rate at 17 to 50 percent), the U.S. Preventive Services Task Force, a government-backed volunteer group of national medical experts, recommend in 2012 to stop routine PSA testing among asymptomatic men in all age groups.
The Task Force breaks down the benefits and risks of routine screening in asymptomatic men this way:
- Five in 1,000 men will die of prostate cancer without screening, while four in 1,000 men will die of prostate cancer with screening. This means one life out of 1,000 will be saved with screening.
- Prostate cancer screening causes false positives in up to 120 men per 1,000 tested.
- About 110 men in 1,000 will be diagnosed with prostate cancer, and 90 percent of these men will have treatment that could cause serious cardiovascular events, deep venous thrombosis, urinary incontinence, erectile dysfunction and death. The Task Force considers these risks unacceptable, or at least questionable, considering the fact most men with prostate cancer have a tumor that was never going to kill them.
The American Cancer Society, another organization that releases screening guidelines, recommends that men and doctors discuss the known risks and benefits of a PSA test, and then make a decision about screening that best fits in with that man’s life and medical history.
As Stiller notes in his essay, for most average-risk men who decide to get screened, testing will start at age 50. Men at high risk of developing prostate cancer, like African Americans or men with a father, brother or son who had prostate cancer at an early age, should discuss screening at age 45, while men with more than one first-degree relative with early prostate cancer should talk to their doctor at age 40.
The average age of prostate cancer diagnosis is 66 years old, but early diagnoses like Stiller’s (he was 46 at his first PSA test) make the case for earlier screening for certain men. After all, the younger you are when you get it, the more years you have to lose if the tumor turns out to be aggressive or deadly.
Ben Stiller’s prostate cancer journey
Stiller didn’t fit any of those high risk categories and yet, at age 46, his doctor Bernard Kruger administered a PSA test to establish a “baseline” for Stiller’s normal PSA levels. Kruger continued to monitor Stiller’s PSA levels every six months, and realized that over 18 months, Stiller’s levels kept rising.
Kruger sent Stiller to a urologist, who administered a digital rectal exam and then recommended an MRI scan to see his prostate in more detail. After the MRI came a biopsy to test the tissue for cancer, and they found that Stiller had “mid-range aggressive cancer.”
Stiller decided to get a prostatectomy, which is a surgery to remove all or part of the prostate gland. Since then, the cancer has not returned.
Stiller writes that his treatment might look very different if Kruger had not taken the initiative to screen Stiller early.
If he had waited, as the American Cancer Society recommends, until I was 50, I would not have known I had a growing tumor until two years after I got treated. If he had followed the US 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.
So should you follow Ben Stiller’s example? Experts weigh in
When asked about prostate cancer patients like Ben Stiller, experts said that his case presents a complex truth about this particular illness: while it’s difficult to convince prostate cancer survivors otherwise, early screening is less likely to save a life than it is to result in serious medical complications that harm people more than the tumor ever would.
“The problem that the medical community has struggled with regarding the PSA test is that for every PSA success story, there’s another man who has been unnecessarily treated as a result of an elevated PSA,” said Dr. Timothy J. Daskivich, a urologic oncologist and director of health services research for the Cedars-Sinai department of surgery in Los Angeles. “These are often men with low-grade cancers (the most common type of prostate cancer in the U.S.) or men with limited life expectancy.”
Stiller’s experience is counter to most medical recommendations about how to screen for prostate cancer, but his story represents a larger trend, according to Dr. Inderbir Gill, chairman of the USC Institute Of Urology at the University of Southern California.
Gill believes that while the 2012 recommendations played an important role in alerting the public to the dangers of overdiagnosis and overtreatment, the field has become much more sophisticated in the past four years.
In fact, Gill said that Stiller’s case is an example of how prostate cancer care has become highly personalized, informed by high-tech testing that involves MRI scans, genomic markers and molecular markers to stratify patients into low, medium and high-risk cases.
Gill said that Stiller’s anecdote is an example of the fact that doctors are having sophisticated conversations with their patients about the risks and benefits of screening, and that treatment has become highly personalized, informed by high-tech testing.
This relies on educating patients about what a PSA level really means. While testing positive for elevated PSA levels used to mean anxiety, fear and medical interventions, now we know that abnormally high levels don’t necessarily mean men should rush to treatment. It could simply mean that men need more monitoring to see if anything worsens over time, as Stiller did.
So what are a doctor and patient to do? Daskivich endorses the ACS’ approach: selectively screen men based on their risk factors, life expectancy and health status. He also agrees with Gill’s assertion that there are now ways to stratify risk so that doctors and patients can choose whether or not to even treat a tumor.
“By doing this, we will target screening and treatment to those who need it, to minimize harms and maximize benefits of screening and treatment,” he concluded.
If Stiller’s story has you wondering about prostate cancer screening, talk to your doctor about the risks and benefits of the PSA test for someone of your age, ethnicity and medical history.