Kristine Warner wanted an eye-catching way to encourage men to talk to their doctors about the complicated, controversial subject of prostate cancer screening.

Don't Fear The Finger campaign was born.

Go ahead and snicker. It got your attention.

The finger in question, of course, is the one a physician puts up a man's rectum to feel for cancer in his prostate gland. The rectal exam is usually paired with a PSA blood test.

Warner, a graphic designer, former lobbyist, and urologist's daughter, is the volunteer director of the Pennsylvania Prostate Cancer Coalition. It launched Don't Fear the Finger in the spring at a rally replete with 2-feet-tall foam cutouts of the digit. SEPTA buses sported posters of guys who aren't afraid of the finger, including a lumberjack and a burly, tattooed biker dude.

While the campaign may be unusually edgy, its goal is not unusual. Across the country, prostate cancer advocacy groups are brainstorming and barnstorming to try to counter an apparent decline in PSA screening rates. The fall-off is the fallout from the U.S. Preventive Services Task Force's game-changing 2012 recommendation against routine PSA testing because, in the view of the influential panel of experts, the harms outweigh the benefits.

Men who ask for PSA tests, the task force said, should be counseled about the pros and cons. The American Academy of Family Physicians promptly updated its advice to match the panel's position.

Other expert groups have since countered with varying screening guidelines that consider the man's age and risk factors - but anecdotally, many primary care doctors have simply stopped offering and ordering the test.

"Family doctors are confused. Even urologists are confused," said Vincent Fiorica, a Johnstown urologist and president of the Urological Association of Pennsylvania. "In the last three years, the number of patients referred to us [by family physicians] has dropped dramatically. I've had conversations with oncology friends and they're afraid we'll go back to the old days where men show up with widely metastatic disease."

On Tuesday, the Pennsylvania Prostate Cancer Coalition will hold a rally at the state capitol, where advocates are exploring another way to promote screening: a law. Sen. Mike Brubaker (R., Lancaster), a prostate cancer survivor, will introduce a bill to create a task force that would, among other things, develop uniform state screening guidelines.

At least five states have already passed pro-screening laws, Warner said.

Prostate is the most-diagnosed cancer among Pennsylvania men. But in this state, as nationwide, both incidence and death rates have been falling since 2007.

The preventive services task force concluded that the best scientific evidence shows little, if any, decline in deaths is due to the introduction of PSA screening in the 1990s - a finding that screening proponents passionately disagree with.

Prostate cancer usually grows slowly over a decade or more. The PSA test, which measures the level of a blood protein shed by the prostate gland, can't distinguish indolent from deadly tumors, or even malignant from benign conditions such as prostate enlargement. Thus, the task force said, "most cancers found by PSA screening . . . will not cause a man any harm during his lifetime."

An elevated PSA test that leads to a diagnosis and unnecessary treatment, however, can do serious harm: damage to bladder, bowel, or sexual function, or a combination, is relatively common.

In 2008 - four years before rejecting screening in general - the task force recommended against screening men age 75 or older. Over the next two years, the rates of both PSA testing and early-stage tumors diagnosed among this age group declined sharply, according to an analysis by Emory University health policy researcher David Howard.

Now, all expert groups, including the American Cancer Society and the American Urological Society, say men with a life expectancy under 10 years should not be screened.

But there is resistance even to this. Howard found that 42 percent of men over 75 still undergo PSA screening. And this month, the Pennsylvania Medical Society used Grandparents Day to urge "grandfathers and older men" to "talk to your physician about possibly being screened."

Although the society's news release touted the Don't Fear the Finger campaign as well as Tuesday's rally in Harrisburg, Warner distanced her cancer coalition from the grandpop angle, saying "that was the medical society's hook."

African American men are another sensitive issue in the screening debate because they are more likely to develop and to die of prostate cancer than white men. Two Don't Fear the Finger posters feature black men.

Such targeting worries Otis Brawley, chief medical officer of the American Cancer Society. He's against screening, even though he is black.

"People think screening can only be good," Brawley said. "But a lot of people, including doctors, are not up to date. They don't tell the whole truth, and they don't respect the man's right to make his own decision."

Part of the tension is that prostate cancer, like all health care, is a business. Health fairs that offer free PSA tests are often sponsored by drug companies that benefit from finding cancer patients. (The finger campaign got about $10,000 from two such companies, Warner said.)

Patrick Walsh, the eminent Johns Hopkins University urological surgeon who pioneered nerve-sparing prostate removal surgery, backs screening but sees the pitfalls: "If doctors do PSA tests, they have a chance to make money. If the man has cancer, there's a chance to make more money."

Screening advocates acknowledge the quandaries and limits of screening. But they see answers in the increasingly judicious use of the PSA, the advent of better tests, and the growing practice of carefully monitoring - rather than immediately treating - men who have early, nonaggressive cancer.

"Discouraging a simple and inexpensive blood test is not the way to address concerns about appropriate treatment for a disease once it is diagnosed," said Scott Owens, a Camp Hill urologist and coalition leader. "We should not throw out the proverbial baby with the bathwater."

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