Prostate cancer screening:
to get or not to get PSA testing?

Making sense of the USPSTF recommendation

Reza Shirazi, MD, DABR, Donald B. Fuller, MD

(October 14, 2011)
September was prostate cancer awareness month.  Prostate cancer screening including a PSA test and digital rectal examination was advocated starting at age 40-50 depending on risk factors and continuing annually in men with a 10 year life expectancy.

A draft of the USPSTF (United States Preventative Services Task Force) recommendation was made public late last week and full recommendation will be published this week in regards to prostate cancer screening.  The draft argues against PSA (prostate specific antigen) screening in healthy men.  The same task force, which is a US government backed panel of primary care physicians, mostly academics, made a controversial recommendation against screening mammogram in certain women back in 2009.  The concern is that government and private insurers use these recommendations to make decisions on what to cover and not cover for screening and treatment purposes of a disease entity.  Because of the public and political outcry, Medicare ultimately decided to cover screening and treatment of breast cancer in this group of patients.

PSA is a protein that is specific to prostate and passively makes its away into the bloodstream and can be detected by a simple blood draw. It is an indicator of how the prostate is behaving. PSA level can be elevated for many reasons and therefore is not very specific.  However, it is the best/ cheapest surrogate marker that we have.  PSA levels can rise because of infection, inflammation, ejaculation, as we age or because of cancer. What the PSA level provides is an indicator that brings our attention to the prostate and may prompt further workup or treatment, including antibiotics, biopsy, etc.

With the FDA approval of PSA in the1980’s and widespread use for screening in 1990’s, we are now detecting prostate cancer at early stages where there are more treatment options available. Thanks to successful screening efforts (including PSA and digital rectal exam), nowadays we rarely see men present with widely metastatic disease as they did 20 years ago.

The prostate cancer death rate has decreased by 33% in the last 15 years, according to the American Cancer Society (ACS). Remarkably, this reduced prostate cancer mortality rate during the "PSA era" is not even contemplated in the USPTS draft report, which instead, focused solely on the smaller comparative studies.

So why all the controversy?

In the era of record deficits and needed cost cutting measures in government spending, including a desire for reduced healthcare spending, a recommendation such as this may be attractive, clearly decreasing utilization of complex healthcare resources by prostate cancer patients. Over the longer term though, abandonment of early detection and appropriate treatment potentially pushes us back to where we were 20 years ago - a time when prostate cancer patients routinely presented with advanced bone metastases, terminal spine pain, kidney failure, paralysis and slow wasting - an excruciating price.

There were five studies that the task force looked at for screening for prostate cancer.  Many of them were flawed in design and some were just misinterpreted. In fact the largest, a European study of 182,000 people in 7 countries, actually showed a 20% reduction in prostate cancer death in the screening group.  The Göteborg study showed an even more impressive  44% cancer death reduction in the PSA screened group. The same studies were reviewed by American Cancer Society and American Urologic Association (AUA) and different conclusions and recommendations have been reached. AUA recommends screening to start at age 40, and American Cancer Society recommends screening to be considered starting at age 40-50 depending on risk factors of men who have 10 years life expectancy.

The task force argues that since prostate cancer is a slow-growing disease, and in many instances patients may never run into trouble from their prostate cancer in their lifetime, they have made this recommendation against PSA screening.  They also cite the potential of possible side effects associated with any treatment for Prostate Cancer.  In fact, studies have shown that for every 12 - 48 prostate cancer patients treated, depending upon their specific age and risk factors, one added life is saved.

So, I guess the question really becomes how much is one life worth?

There is a triangle in delivering healthcare:

  1. 1-Cost: How much the insurers are willing to pay for services rendered.
  2. 2-Coverage: How many people we are willing to cover under the plan.
  3. 3-Quality: What level of care/quality we are comfortable accepting.

We can easily get two out of three corners covered but covering the third corner may, and often is, compromised.

To get or not to get a PSA testing?

Prostate cancer screening consideration including a PSA test, and digital rectal examination starting at age 40-50 (depending on risk factors) and continuing annually on men with a 10 year life expectancy is what I am recommending to my patients and primary care colleagues.  As long as we as physicians and our patients are educated and fight for the level of care the patient expects to receive, I am hopeful.

Reza Shirazi, MD, DABR
Chairman of leadership council of American Cancer Society, San Diego
Cancer liaison physician at Alvarado Hospital, CoC of American College of Surgeons
Member of cancer committee at Palomar and Pomerado hospitals
Radiation Oncologist at Genesis Healthcare Partners

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PSA Screening Response