This week, on Howard Stern‘s radio show, actor Ben Stiller revealed that he was diagnosed with prostate cancer two years ago, at the age of 48!
Stiller says he was diagnosed based on the results of a PSA test:
“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.”
Stiller’s internist, Dr. Bernard Kruger, watched his PSA steadily rise for a year and a half. He was referred to a urologist, who ordered an MRI to look more closely at his prostate, and recommended that Ben undergo a biopsy. As Stiller wrote in an essay on Medium, “Then the biopsy came back positive. Of course “positive” for medical tests is usually not so positive. I had a Gleason score of 7 (3+4), which is categorized ‘mid-range aggressive cancer.’ ”
“At first, I didn’t know what was going to happen. I was scared … It came out of the blue for me,” Stiller told Stern.
Before making a treatment decision, Stiller learned as much as he could about his options, and got second opinions. He also called his friend and “Meet the Fockers” co-star Robert DeNiro, who had been treated for prostate cancer himself in 2003. He ultimately decided to undergo a robotic assisted laparoscopic radical prostatectomy by a surgeon, Dr. Edward Schaeffer, with whom he felt comfortable. Dr. Schaeffer was able to remove all the cancer, and Stiller has remained cancer-free for the past two years. He still continues to get frequent PSA tests, looking for any signs of recurrence.
Stiller credits his PSA screening with saving his life, and urges other men to consider whether testing is right for them. He acknowledges that routine screening with PSA is no longer recommended by the USPSTF (see below), but said:
“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.”
In the late 1960s and early 1970s, medical researchers were searching for proteins that were present only in the prostate gland and no other organs or tissues of the body. If such a protein could be identified, it might possibly be important as a target for treatment or as a biomarker for the presence of prostate cancer. A number of scientists, including Dr. Richard Ablin and Dr. Ming Chu, succeeded in identifying a protein that was present only in prostate tissue and called it prostate specific antigen, better known today as PSA. Apart from being specific to prostate tissue, it also became clear that the normal, biological function of PSA is to break down other proteins in seminal fluid to make it more liquid.
Cancer cells retain the ability to make PSA which leaks into the bloodstream from tumors, raising the level of PSA in the bloodstream. But, an elevation of PSA is not limited to only cancer cells. Baseline levels of PSA increase normally with age. Other diseases, such as benign prostatic hypertrophy (BPH) and prostatitis (an infection of the prostate gland) can also cause elevated levels.
The FDA first approved the PSA test in 1986 to monitor the progression of prostate cancer in men who had already been diagnosed. In 1994, the FDA approved the use of the PSA test in conjunction with a digital rectal examination (DRE) to test asymptomatic men for prostate cancer. Until recently, many doctors and professional organizations encouraged yearly PSA screening for men, beginning at age fifty. Some recommended that men at a higher risk of prostate cancer, including African American men and those whose father or brother had prostate cancer, begin screening at age forty or forty-five.
However, as more is learned about both the benefits and harms of prostate cancer screening, a number of organizations, including the U.S. Preventive Services Task Force (USPSTF), have begun to caution against routine population screening. Several randomized trials of prostate cancer screening have been carried out. One of the largest is the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial. The study, conducted by the National Cancer Institute, was designed to determine whether certain screening tests can help reduce the numbers of deaths from several common cancers. In the prostate portion of the trial, the PSA test and DRE were evaluated for their ability to decrease a man’s chances of dying from prostate cancer. The investigators found that men who underwent annual prostate cancer screening had a higher incidence of prostate cancer than men in the control group, but the same rate of deaths from the disease. These results suggest that many men who were treated for prostate cancers would not have had the disease detected in their lifetime without screening. Consequently, these men were exposed unnecessarily to the potential harms of treatment.
For several reasons, the USPSTF (United States Preventative Services Task Force) no longer recommends routine screening. As the above study showed, detecting prostate cancer early may not reduce the chance of dying from prostate cancer. When used in screening, the PSA test can help detect small tumors that do not cause symptoms. Finding a small tumor, however, may not necessarily reduce a man’s chance of dying from prostate cancer. Some tumors found through PSA testing grow so slowly that they are unlikely to threaten a man’s life.
Detecting tumors that are not life threatening is called overdiagnosis, and treating these tumors is called overtreatment. Overtreatment exposes men unnecessarily to the potential complications and harmful side effects of treatments for early prostate cancer, including surgery and radiation therapy. The side effects of these treatments include urinary incontinence (an inability to control urine flow), problems with bowel function, erectile dysfunction (loss of erections or an inability to have and maintain sexual intercourse), and infection.
If a PSA test is higher than normal, a biopsy of the prostate may be done. Complications from a biopsy of the prostate may include fever, pain, blood in the urine or semen, and urinary tract infection. Even if a biopsy shows no prostate cancer, a patient may worry more about developing it in the future. False-negative test results can also occur. They may appear to be normal even though prostate cancer is present. A man who receives a false-negative test result—one that shows no cancer when there really is—may delay seeking medical care even if he has symptoms. False-positive test results are possible, too. Screening results may appear to be abnormal even though no cancer is present. A false-positive test result—one that shows cancer when there really isn’t—can cause anxiety and is usually followed by more tests, such as a biopsy, which also have risks.
The current USPSTF recommendations are as follows:
Perhaps a simpler way to look at this is this diagram:
All the data discussed above is based on population studies. So what should a population of one (namely you) do?
Talk to your doctor. Make sure that they know your family medical history, not only for prostate cancer, but for any type of cancer. (Your can set up your own “My Family Health Portrait” at https://familyhistory.hhs.gov/FHH/html/index.html.) Get a check up. Then you and your physician can decide whether you are at higher risk. You can also decide whether you would like to get a baseline PSA test, intermittent PSA testing, or digital rectal examinations. Knowledge is empowering. It can help you make the best decisions tailored to your needs.