PSA screening: The USPSTF got it wrong

Prostate cancer is an important disease. It is the second leading cause of cancer death in men who don’t smoke, and in many cases it is detectable early and curable. The rates of both diagnosis and death from prostate cancer in men are similar to the rates of breast cancer in women.¹

The current practical screening test for prostate cancer is the prostate specific antigen (PSA). Making routine use of it, as we know, however, is controversial. The false positive rate for PSA testing is high, for example, in men with chronic prostatitis and benign prostatic hypertrophy.² In addition, many prostate cancers are diagnosed that will never harm the patient. Treatment for prostate cancer may result in complications, such as incontinence and impotence. Because of these facts, the US Preventive Services Task Force (USPSTF) has recommended against routine screening.²

The PSA test itself never hurt anyone

It is just a lab value, a piece of information. What doctors do with the information is the issue. Physicians may cause more harm than good by being overly aggressive with elevated PSA levels and indolent or low-grade prostate cancer—and 75% of prostate cancer is considered indolent (Gleason score of 6 on biopsy).³ Patients with such a finding can be watched, using active surveillance. The majority will never need treatment.³

The PSA test is just a piece of information. What doctors do with the information is the issue.Common sense tells us we must screen for prostate cancer. Not doing so on the basis of evidence-based medicine is not a defense when advanced cancer is diagnosed and screening was not offered to the patient.⁴ Rather than using the data from past physician behavior and recommending against screening with PSA, the USPSTF should have criticized the response to PSA test results and recommended a better way. I see this change rapidly becoming current practice.

PSA testing saves lives

Since the early 1990s, when PSA testing became widespread, there has been a 40% decline in prostate cancer mortality.⁵ A randomized trial in 7 countries in Europe clearly showed a survival benefit from screening for prostate cancer.⁶ Clinical trials in the United States have been ambiguous.

Not screening for prostate cancer with PSA is unacceptable to many physicians and patients. Most physicians have seen preventable prostate cancer deaths. Two patients in my practice illustrate this point. The PSA of one of them—a 62-year-old man—went from 2.4 to 24 in 2 years. The PSA of another, age 56, went from 2.6 to 34 in one year. Both men had no symptoms, and their prostate cancer was found on routine screening. Both had a high Gleason score and locally invasive prostate cancer. Now, years after undergoing cancer treatment, both have undetectable PSA levels and full function. They think the USPSTF’s recommendation not to screen is evidence of the government’s attempt to save money, reinforcing the notion that the government cannot be trusted.

Patients are increasingly savvy

With all the controversy around prostate cancer screening and the adverse effects of treatment, patients are getting savvier. Shared decision making between doctor and patient is becoming the standard of care, and physicians can meet their professional obligations by offering screening and answering any questions the patient may have. I find that most men with low-grade disease are happy to avoid surgery and radiation if active surveillance is offered and explained.

The American Academy of Family Physicians adopted the recommendation of the USPSTF to advise against screening for prostate cancer.⁷ The American College of Physicians recommends that men ages 50 to 69 be given the opportunity for informed decision making before screening.⁸ The American Urological Association recently recommended that men ages 55 to 69 be offered screening, with a discussion about the risks and benefits⁹; and the American Cancer Society recommends screening starting at age 50, and earlier for high-risk men.¹⁰

Not satisfied that any of these organizations really knows what is best and aware that the data are confusing and evolving, I continue to follow my overall practice approach: Start routine cancer screening at age 50 in the general population and at age 40 for high-risk groups. This works for colon, breast, and prostate cancer, the big 3 that are common, sometimes fatal, and often curable with early detection. Recommending against screening for prostate cancer is not tenable.

Men in my practice are offered a PSA test starting at age 50, and every one to 2 years thereafter based on both patient preference and the results. Black men and those with a family history of prostate cancer before age 60 are offered screening starting at age 40. I suggest that screening be stopped at age 80, or earlier if the patient has a serious chronic illness with a life expectancy of less than 10 years.

Active surveillance for low-grade disease
What is done with elevated or rising PSA levels is most controversial, with lots of room for doing harm. Dramatic rises in PSA, like those of the patients I described earlier, are easy: Go right to biopsy and usually, treatment. Gleason 6 prostate cancer is likely to remain localized and indolent, and not threaten life. I work with urologists who are not aggressive and are willing to follow patients with PSA levels up to 10. Noninvasive options are available, such as fractionating the PSA (free and total) and imaging such as MRI. Genetic testing is available and can add to the evaluation of the patient’s risk.

Active surveillance has become a standard of care in monitoring patients with low-grade disease. The outcomes for survival with active surveillance are as good as radical prostatectomy.¹¹ The goal is to be aggressive in treatment only with patients who have life-threatening disease. A collaboration among the patient, the primary care physician, and the urologist is crucial to optimizing patient outcomes.

Recommending against screening for prostate cancer is not tenable. The responsible approach is to continuously improve cancer detection and therapy to maximize good and minimize harm. This approach is available today.

Prostate cancer is an important disease. It is the second leading cause of cancer death in men who don’t smoke, and in many cases it is detectable early and curable. The rates of both diagnosis and death from prostate cancer in men are similar to the rates of breast cancer in women.¹

The current practical screening test for prostate cancer is the prostate specific antigen (PSA). Making routine use of it, as we know, however, is controversial. The false positive rate for PSA testing is high, for example, in men with chronic prostatitis and benign prostatic hypertrophy.² In addition, many prostate cancers are diagnosed that will never harm the patient. Treatment for prostate cancer may result in complications, such as incontinence and impotence. Because of these facts, the US Preventive Services Task Force (USPSTF) has recommended against routine screening.²

The PSA test itself never hurt anyone

It is just a lab value, a piece of information. What doctors do with the information is the issue. Physicians may cause more harm than good by being overly aggressive with elevated PSA levels and indolent or low-grade prostate cancer—and 75% of prostate cancer is considered indolent (Gleason score of 6 on biopsy).³ Patients with such a finding can be watched, using active surveillance. The majority will never need treatment.³

The PSA test is just a piece of information. What doctors do with the information is the issue.Common sense tells us we must screen for prostate cancer. Not doing so on the basis of evidence-based medicine is not a defense when advanced cancer is diagnosed and screening was not offered to the patient.⁴ Rather than using the data from past physician behavior and recommending against screening with PSA, the USPSTF should have criticized the response to PSA test results and recommended a better way. I see this change rapidly becoming current practice.

PSA testing saves lives

Since the early 1990s, when PSA testing became widespread, there has been a 40% decline in prostate cancer mortality.⁵ A randomized trial in 7 countries in Europe clearly showed a survival benefit from screening for prostate cancer.⁶ Clinical trials in the United States have been ambiguous.

Not screening for prostate cancer with PSA is unacceptable to many physicians and patients. Most physicians have seen preventable prostate cancer deaths. Two patients in my practice illustrate this point. The PSA of one of them—a 62-year-old man—went from 2.4 to 24 in 2 years. The PSA of another, age 56, went from 2.6 to 34 in one year. Both men had no symptoms, and their prostate cancer was found on routine screening. Both had a high Gleason score and locally invasive prostate cancer. Now, years after undergoing cancer treatment, both have undetectable PSA levels and full function. They think the USPSTF’s recommendation not to screen is evidence of the government’s attempt to save money, reinforcing the notion that the government cannot be trusted.

Patients are increasingly savvy

With all the controversy around prostate cancer screening and the adverse effects of treatment, patients are getting savvier. Shared decision making between doctor and patient is becoming the standard of care, and physicians can meet their professional obligations by offering screening and answering any questions the patient may have. I find that most men with low-grade disease are happy to avoid surgery and radiation if active surveillance is offered and explained.

The American Academy of Family Physicians adopted the recommendation of the USPSTF to advise against screening for prostate cancer.⁷ The American College of Physicians recommends that men ages 50 to 69 be given the opportunity for informed decision making before screening.⁸ The American Urological Association recently recommended that men ages 55 to 69 be offered screening, with a discussion about the risks and benefits⁹; and the American Cancer Society recommends screening starting at age 50, and earlier for high-risk men.¹⁰

Not satisfied that any of these organizations really knows what is best and aware that the data are confusing and evolving, I continue to follow my overall practice approach: Start routine cancer screening at age 50 in the general population and at age 40 for high-risk groups. This works for colon, breast, and prostate cancer, the big 3 that are common, sometimes fatal, and often curable with early detection. Recommending against screening for prostate cancer is not tenable.

Men in my practice are offered a PSA test starting at age 50, and every one to 2 years thereafter based on both patient preference and the results. Black men and those with a family history of prostate cancer before age 60 are offered screening starting at age 40. I suggest that screening be stopped at age 80, or earlier if the patient has a serious chronic illness with a life expectancy of less than 10 years.

Active surveillance for low-grade disease
What is done with elevated or rising PSA levels is most controversial, with lots of room for doing harm. Dramatic rises in PSA, like those of the patients I described earlier, are easy: Go right to biopsy and usually, treatment. Gleason 6 prostate cancer is likely to remain localized and indolent, and not threaten life. I work with urologists who are not aggressive and are willing to follow patients with PSA levels up to 10. Noninvasive options are available, such as fractionating the PSA (free and total) and imaging such as MRI. Genetic testing is available and can add to the evaluation of the patient’s risk.

Active surveillance has become a standard of care in monitoring patients with low-grade disease. The outcomes for survival with active surveillance are as good as radical prostatectomy.¹¹ The goal is to be aggressive in treatment only with patients who have life-threatening disease. A collaboration among the patient, the primary care physician, and the urologist is crucial to optimizing patient outcomes.

Recommending against screening for prostate cancer is not tenable. The responsible approach is to continuously improve cancer detection and therapy to maximize good and minimize harm. This approach is available today.

Prostate cancer is an important disease. It is the second leading cause of cancer death in men who don’t smoke, and in many cases it is detectable early and curable. The rates of both diagnosis and death from prostate cancer in men are similar to the rates of breast cancer in women.¹

The current practical screening test for prostate cancer is the prostate specific antigen (PSA). Making routine use of it, as we know, however, is controversial. The false positive rate for PSA testing is high, for example, in men with chronic prostatitis and benign prostatic hypertrophy.² In addition, many prostate cancers are diagnosed that will never harm the patient. Treatment for prostate cancer may result in complications, such as incontinence and impotence. Because of these facts, the US Preventive Services Task Force (USPSTF) has recommended against routine screening.²

The PSA test itself never hurt anyone

It is just a lab value, a piece of information. What doctors do with the information is the issue. Physicians may cause more harm than good by being overly aggressive with elevated PSA levels and indolent or low-grade prostate cancer—and 75% of prostate cancer is considered indolent (Gleason score of 6 on biopsy).³ Patients with such a finding can be watched, using active surveillance. The majority will never need treatment.³

The PSA test is just a piece of information. What doctors do with the information is the issue.Common sense tells us we must screen for prostate cancer. Not doing so on the basis of evidence-based medicine is not a defense when advanced cancer is diagnosed and screening was not offered to the patient.⁴ Rather than using the data from past physician behavior and recommending against screening with PSA, the USPSTF should have criticized the response to PSA test results and recommended a better way. I see this change rapidly becoming current practice.

PSA testing saves lives

Since the early 1990s, when PSA testing became widespread, there has been a 40% decline in prostate cancer mortality.⁵ A randomized trial in 7 countries in Europe clearly showed a survival benefit from screening for prostate cancer.⁶ Clinical trials in the United States have been ambiguous.

Not screening for prostate cancer with PSA is unacceptable to many physicians and patients. Most physicians have seen preventable prostate cancer deaths. Two patients in my practice illustrate this point. The PSA of one of them—a 62-year-old man—went from 2.4 to 24 in 2 years. The PSA of another, age 56, went from 2.6 to 34 in one year. Both men had no symptoms, and their prostate cancer was found on routine screening. Both had a high Gleason score and locally invasive prostate cancer. Now, years after undergoing cancer treatment, both have undetectable PSA levels and full function. They think the USPSTF’s recommendation not to screen is evidence of the government’s attempt to save money, reinforcing the notion that the government cannot be trusted.

Patients are increasingly savvy

With all the controversy around prostate cancer screening and the adverse effects of treatment, patients are getting savvier. Shared decision making between doctor and patient is becoming the standard of care, and physicians can meet their professional obligations by offering screening and answering any questions the patient may have. I find that most men with low-grade disease are happy to avoid surgery and radiation if active surveillance is offered and explained.

The American Academy of Family Physicians adopted the recommendation of the USPSTF to advise against screening for prostate cancer.⁷ The American College of Physicians recommends that men ages 50 to 69 be given the opportunity for informed decision making before screening.⁸ The American Urological Association recently recommended that men ages 55 to 69 be offered screening, with a discussion about the risks and benefits⁹; and the American Cancer Society recommends screening starting at age 50, and earlier for high-risk men.¹⁰

Not satisfied that any of these organizations really knows what is best and aware that the data are confusing and evolving, I continue to follow my overall practice approach: Start routine cancer screening at age 50 in the general population and at age 40 for high-risk groups. This works for colon, breast, and prostate cancer, the big 3 that are common, sometimes fatal, and often curable with early detection. Recommending against screening for prostate cancer is not tenable.

Men in my practice are offered a PSA test starting at age 50, and every one to 2 years thereafter based on both patient preference and the results. Black men and those with a family history of prostate cancer before age 60 are offered screening starting at age 40. I suggest that screening be stopped at age 80, or earlier if the patient has a serious chronic illness with a life expectancy of less than 10 years.

Active surveillance for low-grade disease
What is done with elevated or rising PSA levels is most controversial, with lots of room for doing harm. Dramatic rises in PSA, like those of the patients I described earlier, are easy: Go right to biopsy and usually, treatment. Gleason 6 prostate cancer is likely to remain localized and indolent, and not threaten life. I work with urologists who are not aggressive and are willing to follow patients with PSA levels up to 10. Noninvasive options are available, such as fractionating the PSA (free and total) and imaging such as MRI. Genetic testing is available and can add to the evaluation of the patient’s risk.

Active surveillance has become a standard of care in monitoring patients with low-grade disease. The outcomes for survival with active surveillance are as good as radical prostatectomy.¹¹ The goal is to be aggressive in treatment only with patients who have life-threatening disease. A collaboration among the patient, the primary care physician, and the urologist is crucial to optimizing patient outcomes.

Recommending against screening for prostate cancer is not tenable. The responsible approach is to continuously improve cancer detection and therapy to maximize good and minimize harm. This approach is available today.