Early Prostate Cancer: To Screen Or Not To Screen?
By Dr. James Palermo // May 25, 2012
(Video by drschiff1)
In October of last year the U.S. Preventive Services Task Force (USPSTF) released a draft recommendation that men age 75 and over did not benefit from routine screening for prostate cancer with prostate specific antigen (PSA) blood testing. In a report recently published in the Annals of Internal Medicine, the USPSTF issued a final recommendation on routine screening for prostate cancer that recommends against PSA blood testing for all healthy men irregardless of age.
The recommendation does not apply to the use of PSA testing for monitoring patients after a prostate cancer diagnosis or treatment.
Task Force Rationale
Calling prevention of prostate cancer deaths the primary goal of screening, the task force cited a lack of evidence that PSA testing has an impact on that goal. According to USPSTF findings, PSA testing is likely to save the life of just one in 1,000 men, and in their report members of the task force said, “There is convincing evidence that the number of men who avoid dying of prostate cancer because of screening after 10 to 14 years is, at best, very small.”
The Task Force bases its recommendations on their findings that at present, there is no way to tell for sure which cases of prostate cancer are life-threatening and require treatment, and which cases are not. Most prostate cancer grows very slowly, and many men with prostate cancer die of something other than prostate cancer. However, screening puts men at risk for unnecessary worry and adverse effects of surgical treatment, hormones, or radiation therapy.
“This is important information for the public and men to have, and they should talk with their doctors about the risks and benefits of prostate cancer screening and make the decision that’s best for them,” Health and Human Services spokesperson Mark Weber said.
The Task Force does leave room for PSA testing within the physician-patient relationship but emphasizes that physicians have an obligation to ensure that the patient has an understanding of risks and unproven benefits.
Task Force Recommendations Controversial
Although the American Cancer Society has endorsed the USPSTF recommendations, other well recognized prostate cancer experts criticized the Task Force’s stand on testing. The vice chairman of the health policy council of the American Urological Association (AUA) David Penson, MD, said, “The recommendation was not unexpected but was nonetheless disappointing.” Penson and his colleagues at the AUA, and other critics of the recommendations believe that the USPSTF has underestimated the benefits and overestimated the harms of prostate cancer screening, and suggest that physicians review the evidence and individualize prostate cancer screening decisions on the basis of informed patient preferences.
Terrence Regan, MD of Palm Coast, president of the Florida Urological Society said, “While the group meant well, the data is flawed. We think screening for prostate cancer does save lives if performed on well-informed healthy men who have at least a 10-year life expectancy.”
Regan points out that the USPSTF guidelines are only recommendations and not an official mandate. In fact, the Florida Prostate Cancer Advisory Council released a report in November concluding that men age 50 and up should be given the option of a PSA test, which shows markers indicating trouble in the prostate gland, every year after being fully informed of the risks and benefits. The screening should begin at 40 for African-Americans and for men who have a family history of the disease.
Task Force Recommendations May Have Impact On Coverage
Despite the USPSTF recommendations, the Obama administration confirmed that Medicare will, at least for now, continue to pay for PSA screening. However, it remains to be seen whether or not that coverage will be compromised in the foreseeable future based on the fact that in the healthcare reform act coverage for preventive services is tied to graded recommendations established by the USPSTF. Unfortunately, graded recommendations by the USPSTF like this related to PSA screening may well affect both Medicare and commercial coverage and ultimately limit access for some patients who decide they want to have screening.