“D” is for Divisive: US Preventive Health Services Task Force Recommends Against PSA Testing

Published: August 6, 2012

Michael E. Franks, M.D.Recent USPSTF recommendations have given PSA screening a “D” grade, that is, they do not feel the risks outweigh the benefits. As a Urologist who practices in Urologic Oncology and Prostate Cancer, I am disappointed in this conclusion as the dust has settled in the blogosphere with varying opinions put forth. Review of the task force paper shows that not one of the panel members is a practicing urologist or medical oncologist, which means they do not have experience in the nuances and individualization of prostate cancer risk and treatments. The AMA and Urologic groups (AUA, LUGPA) have recommended a stepwise review of panel recommendations with the addition of members to these panels who have experience treating the particular disease, and legislative support has followed as a result. This is a sensible approach.

On review, the USPSTF gets it wrong in that their statement does not separate the diagnostic ability of PSA to detect prostate cancer from treatment effects or outcomes. At this time, prostate biopsy is the only way to tell if prostate cancer is present for one, and more importantly, whether it may be clinically relevant or life threatening. PSA screening should continue to be individualized based on overall health, race, and family history in the setting of these potential risks of “overtreatment. We as urologists need to do a better job with patient discourse of the active surveillance option, but ultimately, patients will make their own decisions regarding therapy based on their evaluation of the information and options, and their cultural beliefs. At Virginia Urology, where we have treated over 10,000 patients with prostate cancer over 15 years, with 10% of diagnosed patients going on an observational strategy – we probably need to do more of this in the future, with clinical support in recent studies noted.  As a group, urologists do not have a clear line in the sand for those men diagnosed where we can guarantee that watchful waiting won’t harm them in the short or long term, and surgical treatments won’t cause undue side effects like ED or incontinence. At Virginia Urology, we are currently investigating our robust database to look for clues for better selection of active surveillance patients.

I feel that the USPSTF has also underestimated the benefits of prostate cancer testing. Currently, PSA is the most widely used screening test for CAP, and allows for detection of prostate cancer at its earliest stages – before it has spread beyond the prostate. This is supported from various studies, and the reduction in the prostate cancer specific mortality has been demonstrated from 1990 – 2009. The ERSPC, Goteborg Trial showed a 44% relative risk in prostate cancer mortality in men 50-64 after 14 years median follow-up using a screening PSA cutoff of 3.0 ng/ml. The PLCO study, the data which formed the basis of the opinions of the USPSTF, certainly was flawed from the beginning. Comparing PSA screened patients to a control group with “opportunistic screening” rather than no screening, unfortunately just confuses the picture.  A secondary evaluation of the PLCO data by Crawford, Et al, interestingly showed a 20% benefit to PSA screening in the healthier men in the study. Reasonable review of the data shows a reduction in prostate cancer death rate in certain patient cohorts as well as improved survival in men over the last 20 years, which in part is likely due to a screening effect on the downward stage migration of prostate cancer we see currently in a large, integrated community practice.

The main caveat not realized by the USPSTF is that prostate cancer needs to be found in the treatable stage, and that PSA screening and testing is the most useful vehicle along with DRE to obtain this goal, via prostate biopsy. In my opinion, PSA screening, patient selection factors and improved surgical/radiation techniques, seem to have made a difference in the prostate cancer death rate. At what financial cost is another blog story. Until imaging modalities like MRI become less invasive and more sensitive and specific for diagnostic purposes, PSA screening is as useful as mammography and it is what we have at our disposal at this time. A salient and reasonable discussion about these studies can lead myself and others to say yes to PSA screening. Shame on the USPSTF for their myopic view of the PSA screening saga. I give them a “D” grade as well.

1 Active Surveillance in the Management of Men With Localized Prostate Cancer. NIH Consens State Sci Statements. 2011 Dec 5–7;28(1):1–27.
2 U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2008 Incidence and Mortality Web-based Report. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2012. Available at: http://www.cdc.gov/uscs
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. 5 Etzioni R, et al. The prostate cancer conundrum revisited: Treatment changes and prostate cancer mortality declines. Cancer. 2012 May 17. doi: 10.1002/cncr.27594. (Epub ahead of print.)
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7 Prof Jonas Hugosson MD,Sigrid Carlsson MD,Gunnar Aus MD,Svante Bergdahl MD,Ali Khatami MD,Pär Lodding MD,Carl-Gustaf Pihl MD,Johan Stranne MD,Erik Holmberg PhD,Hans Lilja MD. Mortality results from the Göteborg randomised population-based prostate-cancer screening trial. The Lancet Oncology – 1 August 2010 ( Vol. 11, Issue 8, Pages 725-732 ) DOI: 10.1016/S1470-2045(10)70146-7
8 U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2008 Incidence and Mortality Web-based Report. Atlanta (GA): Department of Health and Human Services, Centers for Disease Control and Prevention, and National Cancer Institute; 2012. Available at: http://www.cdc.gov/uscs
. 9 Ganz PA , Barry JM, Burke W, Col NF, Corso PS, Dodson E, Hammond ME, Kogan BA, Lynch CF, Newcomer L, Seifter EJ, Tooze JA, Viswanath K, Wessells H. National Institutes of Health State-of-the-Science Conference Statement: Role of Active Surveillance in the Management of Men With Localized Prostate Cancer. NIH Consens State Sci Statements. 2011 Dec 5–7;28(1):1–27.
10 Tosoian JJ, Trock BJ, Landis P, Feng Z, Epstein JI, Partin AW, Walsh PC, Carter HB. Active surveillance program for prostate cancer: an update of the Johns Hopkins experience.J Clin Oncol. 2011 Jun 1;29(16):2185-90
11 Crawford ED, Grubb R 3rd, Black A, Andriole GL Jr, Chen MH, Izmirlian G, Berg CD, D’Amico AV.  Comorbidity and mortality results from a randomized prostate cancer screening trial.  J Clin Oncol. 2011 Feb 1;29(4):355-61.