When Screening Fails

I sat listening as the lecturer instructed us about “PSAs.” In my former life – that is, the one before weekly cadaveric dissections, Pomodoro study techniques, and time-blocking my day by lecture — I understood the acronym “PSA” to mean “public service announcement.” I knew this definition didn’t apply given the current context. According to my professor, PSA referred to “prostate-specific antigen,” one of the ways doctors try to find prostate cancer before it becomes clinically apparent. I stopped taking notes mid-sentence and froze. Even though I’d been bracing myself for the inevitable lecture on this topic since medical school started, its arrival still somehow felt like a shock. Unfortunately, prostate cancer wasn’t an unfamiliar condition to me.

PSA is a protein produced by normal as well as malignant cells of the prostate gland. The blood level of PSA is often elevated in men with prostate cancer and can be measured through a simple blood test. In this kind of cancer, the rampant growth of malignant cells usually starts in the rear margin of the prostate, just like a sprinkle on the edge of a donut. In that spot, it hides in silence. Until it doesn’t. When it makes the arduous journey to the urethra, which runs through the hole in that donut, the cancer cells can compress the anatomy, cause physical symptoms, and subsequently clue its victims in to its presence.

This would be the norm of prostate cancer progression if it weren’t for the fact that our healthcare system has gone to great lengths to make sure that the patient isn’t the one to get the clue; the doctors get that clue: one highly-debated number, the PSA result, on a lab report. Questioned due to its lack of definitive meaning and potential risk of disturbing patients whose PSA-emitting cells wouldn’t ever cause symptoms, the PSA test is a double-edged sword. However, we continue to screen; early knowledge helps to benefit many. Those aforementioned lengths that the medical system takes, though? They aren’t the most extensive possible. No, that would mean testing every person with an X and a Y chromosome – that is, every member of the male sex – at every regular check-up. Surely, this is unreasonable. So, instead, medical experts chose an age to start screening. Not willy-nilly, of course. There’s always evidence. Yes, some too young and too old would be missed, but those cases were deemed the ones acceptable to miss.

My dad was at an age deemed acceptable to miss.

My family grappled, “So the cancer is…him? I mean, it’s made of him? But at the same time, it’s attacking him?” They, and I, tried in vain to process the self-destructive juxtaposition. Too young to receive regular screening, my dad had received his first PSA test, as well as many other tests which would confirm his diagnosis, only after experiencing those anatomy-compressing symptoms.

In reality, my dad’s cancer began because a few devious cells had sneakily evaded the human body’s natural “control checks” and were running wild like rebellious high school kids having friends over while the parents are out of town. Since these cells get past the natural filtering system, some patients are outliers of the carefully planned screening measures we take. My dad was made physically aware of his condition for years as he underwent surgeries, radiation, and several rounds of aggressive medication. His pain was tangible, and my family struggled to ease our fear.

While dealing with my dad’s diagnosis, I decided to attempt healthy coping mechanisms by shadowing in the field of urology for a week. Why? I believe the desire stemmed from the lack of control I felt in easing my dad’s suffering. By learning about his condition, I at least felt like I was “doing something.” During my week, I found it difficult to mentally disconnect from seeing my-dad-the-patient in many patients whom I watched the doctor treat. Prostate cancer examinations are, well, intimate; patients can feel extremely vulnerable and uncomfortable, as I know my dad did. As I watched the doctor take histories, perform screenings, and collect biopsies, I admired her meticulousness with each patient. I observed as some patients’ conditions were caught by screening alone, while others succumbed to symptoms.

How do we lessen the burden on the healthcare system without “doing harm” and betraying Hippocrates? It’s a public health issue we face. Morality and finances mix like oil and water sometimes, and the issue complicates further when things get personal, like PSA screening did for my family. I tell myself to buckle up; this may be the first but surely won’t be the last time I feel in opposition to the system I will soon enter as a practitioner. At times, this career path and I have a relationship status of “complicated.” However, millions benefit from screening measures. Millions of lives are saved.

I am energized by the thought of soon participating in these types of preventive procedures as my training progresses further. Screening failed my dad, but I’ve chosen to forgive it. In fact, his very trials inspire me to join the medical efforts toward improving screening measures. After all, his doctors’ names are household names in my family, and I’m eternally grateful for their care.  If I myself can mimic this role for patients one day, I’ll know that I’ve fulfilled my purpose for entering medicine.

At the end of the day, PSA: the PSA saved my dad’s life.