Maybe Bob Dole should get credit for finding a way to make prostate cancer screening free, quick, and even sort of festive.
In 1992, a few years before the PSA test was officially approved for screening, the esteemed U.S. senator and prostate cancer survivor sponsored the first "Bob Dole prostate cancer screening booth," urging men to drop in for the simple blood test - at the Republican National Convention in Houston.
Dole, now 93, later told a Senate committee on aging that he went on to spearhead a slew of booths in places such as the Kansas State Fair, the Chicago Mercantile Exchange, and the 1996 Republican convention, where he became the party's nominee. About 20,000 men got prostate-specific antigen (PSA) tests at no charge.
Free, walk-in PSA screening-fests, often at manly events such as car shows, became a big thing, especially during September, which is prostate cancer awareness month. Advocacy groups, urologists, and hospitals embraced the strategy, presuming that catching cancer early would save lives.
But that strategy - like that presumption - is now seen as dangerously simplistic. Screening prompts treatment of many slow-growing cancers that would not cause problems if left undetected, and major studies have found that routine screening has little impact on mortality rates.
Even the American Urological Association, a fervent PSA defender, says screening should be done only after men and their doctors discuss harms as well as benefits.
The association "came out with a really strong statement that those types of mass screenings should not be done," said H. Ballentine Carter, a Johns Hopkins School of Medicine urologic oncologist who led the group's screening guidelines committee. "There was no gray area."
Free screenings haven't disappeared, but now they often require pre-registration, target higher-risk men such as African Americans - and are a hard sell.
Aria Jefferson Health in Northeast Philadelphia, for example, ran ads in several newspapers and put fliers in doctors' offices to recruit uninsured and underinsured men for a recent screening.
"We marketed it to death," said Katrina Losa, Aria cancer services administrative director. "We still only had 23 men."
The results are mailed
Free screening events vary, but usually men get educational material, fill out a consent form, give a blood sample, then have a rectal exam to see whether the prostate gland feels normal. The PSA results are mailed, but sites typically call men who have elevated levels to advise them to consult a urologist.
Testing men with no symptoms has always stirred controversy. Prostate cancer is common (about 181,000 new cases this year) and often slow-growing, yet the PSA test can't tell which cancers are aggressive. Moreover, there is no "normal" level of the antigen, which is shed by the gland. Studies have found that many men with low levels have cancer, while many with modestly elevated levels - enough to warrant a biopsy - do not.
Four years ago, an influential government advisory panel, the U.S. Preventive Services Task Force (USPSTF), sparked a firestorm by recommending that doctors omit PSA testing from routine health care, even for high-risk men.
Diagnoses of metastatic prostate cancer and death rates fell steadily after widespread PSA use began in 1990. Even so, the panel said the harms of treating innocuous cancers - notably, sexual and urinary side effects - outweighed the benefit of saving "few, if any, lives."
Since that guidance, PSA screening rates, early-stage disease diagnoses - and participation in free screening fairs - all have dropped.
The Prostate Conditions Education Council, a 27-year-old nonprofit, used to bring free or low-cost screenings to 125,000 men a year by working with hospitals and urology practices across the country.
"There has been a dramatic decline," said Leonard G. Gomella, a council board member and chair of urology at Sidney Kimmel Cancer Center at Jefferson. "We've had a 50 to 60 percent decrease in the number of men who come" to free screenings.
The Denver-based council's founder, E. David Crawford, a urologist at the University of Colorado School of Medicine, commended the USPSTF for issuing a needed "wake-up call" about overdiagnosis and overtreatment.
Still, Crawford firmly believes - and the council recommends - a "baseline" PSA test for all men at age 40. (The urological association says to start screening average-risk men at 55.)
Crawford also advocates appealing to men who would otherwise avoid screening - though he doesn't like that word: "Are we doing mass screening, or case finding?"
Roswell Park Cancer Institute, the distinguished center in Buffalo, cosponsors screening events, held at a Sabres hockey game and a car show, that target African Americans and others at high risk. Urology department chair James Mohler also takes issue with the term "mass screening."
"We don't do free mass screening. I would concur that that's inappropriate," he said. "Our events are directed to encourage men at high risk who haven't been tested to get tested. I would call this early detection."
No one knows how many men have been diagnosed with prostate cancer after a free screening revealed a high PSA - or how many were left scrambling because they didn't have health insurance.
Some screening sites strive to make sure that men who need treatment don't fall through the cracks.
,At Aria, for example, Losa said, "we have a very organized process that ensures men are case-managed through the process. We follow up with them to make sure they got care. We connect them with financial counselors if they don't have insurance."
One event going strong
At least one screening event, however, has not changed its come-one-come-all advocacy. Cruisin' for a Cure was launched in Lake Forest, Calif., in 2000 by Debbie Baker after her husband died of prostate cancer that was flagged by a PSA test. Cruisin' is "the world's largest one-day charity car show" with more than 3,500 vehicles, hundreds of vendors, and a big testing venue.
"Any man over 40 can get screened, for free, no appointments. We try to screen 1,500 men a year. We have five [screening] rooms going from 6 a.m. until 4 p.m.," said Baker, who says participation hasn't declined.
"We have proven the PSA test does save lives," she added. "I think the guy should get a PSA test and follow the numbers."
Crawford has a more nuanced view. He believes that in the near future, the PSA's limitations will be diminished by an emerging array of companion "biomarker" tests. These genetic and chemical analyses aim to help identify which men with elevated PSA levels need diagnostic biopsies, and which tumors truly need treatment.
"The USPSTF put a big damper on early detection," he said. "There needs to be a correction. Knowledge is power. You're better off knowing."
Ilene Raymond Rush contributed to this article.