This week the U.S. Preventive Services Task Force (USPSTF) announced its final recommendation against PSA screening for prostate cancer for men of all ages. In 2008 the same panel had recommended against PSA screening for men aged 75 and older, but said the evidence was inconclusive for younger men. Since then, the USPSTF reviewed new evidence on the benefits and harms of PSA testing and the benefits and harms of treating localized prostate cancer. It concluded that, “The harms of PSA-based screening for prostate cancer include a high rate of false positive results and accompanying negative psychological effects, high rate of complications associated with diagnostic biopsy, and — most important — a high risk for overdiagnosis coupled with overtreatment.”
The American Urological Association was outraged by the decision and released a written response stating, “It is inappropriate and irresponsible to issue a blanket statement against PSA testing.”
Portland urologist Gregory Adey, MD, a member of the urological association, says the recommendation is “a disservice to American men. There is data to support that PSA testing saves lives. The studies reviewed by the task force actually do show a survival benefit to PSA screening.”
The task force states there is convincing evidence that PSA-based screening finds many cases of prostate cancer before there are any symptoms, but that a substantial percentage of those cases will either “not progress or will progress so slowly that it would have remained asymptomatic for the man’s lifetime.”
The slide below gives a clinical summary of the USPSTF recommendation.
Several individuals and groups, in addition to Adey and the AUA, had strong reactions to the new recommendation.
In an editorial in the Annals of Internal Medicine, a group of medical professionals said they disagreed with the recommendation and believed that, “the USPSTF has underestimated the benefits and overestimated the harms of prostate cancer screening.”
The authors also believe some of the research the task force reviewed was flawed, writing that, “In addition to misinterpreting the potential effect of the limitations of the 2 largest screening trails, we believe that the Task Force had other flaws in its reasoning. First, it overlooked the fact that diagnostic procedures and related complications occur in unscreened populations as well, and at a later stage of cancer discovery.”
Dr. Otis Brawley, the American Cancer Society’s chief medical officer, who also wrote an editorial in the Annals of Internal Medicine, said he agrees with the recommendation and hopes that it will put an end to mass prostate cancer screenings. He wrote, “I believe that much of the shock about this recent recommendation is because Americans have been taught for decades to fear all cancer and that the best way to deal with cancer is to find it early and treat it aggressively. As a result, many have a blind faith in early detection of cancer and subsequent aggressive medical intervention whenever cancer is found. There is little appreciation of the harms that screening and medical interventions can cause.”
So, where does this leave the millions of American men who are affected by the new recommendation? It makes it even more important for them to talk with their health care providers about their personal risks and benefits and to learn as much as they can about the issues.
Some facts about the prostate
The prostate is a small walnut-shaped gland located between the bladder and the penis, just in front of the rectum. It produces a fluid that nourishes and protects sperm.
Cancer of the prostate is the second most common cancer in men after skin cancer. The National Cancer Institute estimates that in 2012 in the United States 241,740 new cases will be diagnosed and 28,170 men will die from prostate cancer.
Prostate cancer risk factors
- Age: In the U.S., most men with prostate cancer are over 65. It is rare in men under 45.
- Family history: Risk increases if father, brother, or son had prostate cancer.
- Race: More common among black men; also more likely to be aggressive.
- Genes: Inherited genes may cause 5% to 10% of prostate cancer.
- Diet: Studies have shown that men who eat a lot of red meat or high-fat dairy products may have a slightly higher risk.
Where does PSA testing fit in?
A huge issue is that prostate cancer often has no symptoms, which is why PSA testing has been seen as an important diagnostic tool. However, even before the recommendation by the USPSTF, PSA screening was considered controversial. PSA stands for prostate-specific antigen, which is a protein produced by both cancerous and non-cancerous prostate tissue. Normally, a PSA level of 4.0 indicates a healthy prostate. An increased PSA level may be a sign of cancer, but not necessarily. Other conditions can also contribute, leading to a false-positive result. Only about one in four men with a positive PSA test will actually have prostate cancer. Some prostate cancers, especially fast growing ones, do not cause an increase in PSA, which can result in a false-negative, meaning the test could indicate you don’t have prostate cancer when you do. Yes, it can be complicated.
The American Cancer Society, whose medical chief agrees with the recommendation against PSA screening, says before deciding whether or not to be screened, men should discuss the risks and benefits with their doctor.
Dr. Adey may not agree with the recommendation, but he does agree that education is important, not just of men considering PSA testing, but also of the doctors who may or may not be recommending it. “The efforts of the medical community and the task force should be on properly instructing physicians how to properly use PSA to screen men,” he says. “We also must instruct providers to determine the risk of prostate cancer for each male patient. In such a way, we can all properly screen men for prostate cancer, and in turn, save lives. As a nation of men, we must speak loudly, so that this injustice can be heard.”
What about you? What do you think about the recommendation against PSA testing?