By John Sylvester, M.D. –
There has been a great deal of attention in the media recently about PSA screening. The United States Preventative Services Task Force (USPSTF) came out with recommendations that PSA screening should not be done. They recommend no routine PSA blood tests for prostate cancer screening. These recommendations may lead Medicare and private insurance companies to refuse to pay for PSA tests.
Many prostate cancer experts were surprised and frankly upset by the USPSTF recommendations. We feel the USPSTF made some major errors. They made these recommendations after reviewing several articles published in the medical literature. They primarily based their decision on one article published in the New England Journal of Medicine (NEJM) in 2009 “Mortality Results from a Randomized Prostate-Cancer Screening Trial” (the PLCO trial). This paper evaluated whether patients randomized to PSA screening versus “usual care” experienced a reduced risk of death from prostate cancer. It was a poorly run study with major flaws and should not have been used to make any recommendations.
Problems with PLCO Article:
. Only 85% of men in PSA screening arm actually got PSA tests
. At least 52% of men in non-screening arm received PSA screening
. Length of follow-up was too short to show a survival advantage
. PSA cut-off was too high to detect many cancers when they are most curable
Why the USPSTF chose to ignore these major problems was not explained. Moreover, the USPSTF chose to ignore the positive findings in the PLCO study. The “healthy” men who participated in the PLCO were 44% less likely to die of prostate cancer with screening. The 10% of men in the study that had 1-2 PSA checks prior to entering the PLCO trial had a 25% reduction in prostate cancer deaths.
Positive Studies
Other, cleaner randomized studies have been published on PSA screening. The European randomized study from the same issue of the NEJM as the PLCO study was much larger, had less contamination and showed a 20% reduction in prostate cancer deaths initially, and with longer follow-up now shows a 31% reduction in prostate cancer deaths with PSA screening. The smaller but even better run Goteborg randomized trial showed a 44% reduction in prostate cancer deaths with PSA screening (Lancet 2010). Why the USPSTF chose to de-emphasize these better run positive studies was, again, not explained.
During the PSA era, prostate cancer mortality in the USA has dropped ~40-45%, and the percentage of men being diagnosed with metastatic (incurable disease) has dropped ~75%. The USPSTF suggests evaluation and biopsies be considered when men develop symptoms of prostate cancer. Every cancer doctor knows it is usually incurable at that point. But, the USPTF had no cancer doctors on the panel.
PSA Blood Test
The PSA blood test is simply another piece of information a doctor can discuss with his/her patient. Having a rise in PSA does not necessarily mean you need a biopsy. A short course of antibiotics may make the PSA fall, in which case a biopsy may not be needed.
If a biopsy is done and found to be positive for cancer, many options are available to the individual patient. These options include active surveillance, Radical Prostatectomy, Image Guided Intensity Modulated Radiation Therapy (IG-IMRT), Radioactive seed implantation (brachytherapy), hormonal manipulation, Cyrotherapy, etc. If a relatively healthy man is found to have an aggressive cancer, treatment is indicated. If an older less healthy man is found to have a low volume low risk cancer, active surveillance may be the best option. These treatment decisions are best decided by the patient and his physician, not by some government panel that did not even include any prostate cancer doctors.
Less Aggressive Therapy with Screening
Detected Cancers
The USPSTF has made mistakes, it recommended against screening mammography a few years ago for women aged 40-49. This recommendation has subsequently been proven wrong. In Radiology, 2012;262:797-806, Judith Malmgren from the University of Washington in Seattle published that women age 40-49 with screening mammographically detected breast cancer have a lower cancer recurrence rate and require less aggressive therapy than women whose cancer was not detected with screening mammography. In men with PSA detected prostate cancer, we can often treat with less aggressive therapy which results in fewer side effects.
Breaking News (Reported in AMA Wire)
Eliminating prostate-specific antigen (PSA) testing for prostate cancer could result in three times more men with advanced prostate cancer, according to research published in the journal Cancer. They predict metastatic prostate cancer will rise from the current level of 8,000 new cases per year to 25,000 a year if PSA screening is abandoned.
Confusion Regarding New AUA Guidelines: (Commentary by William J Catalona, MD)
“In May of 2013 the AUA released new guidelines recommending PSA screening for men aged 55-69. The reason the AUA did not recommend screening in average-risk men prior to age 55 is because PSA screening has not been adequately tested in a randomized clinical trial (RTC), and there is little evidence from RCTs concerning benefits or harms of PSA testing in men younger than 55 Although the fine print in the AUA guidance document explains that the Panel does not recommend against PSA testing for men 40 to 55 years old, the actual guidelines statement uses the language, “we do not recommend.” Rather, it should read, “there is insufficient evidence to recommend for or against early detection in men younger than 55. The AUA does not recommend routine PSA testing in men older than 69, despite the fact that 50% of prostate cancer deaths occur in men diagnosed after age 75. Age 70 is too young to stop testing in otherwise healthy men who have a 10–15 years or more life expectancy. Therefore, PSA testing in men over 70 should be performed on an individual basis with shared decision making between physicians and patients”
The Bottom Line
While the PSA blood test is not perfect, it is much more sensitive than the digital rectal exam alone in detecting prostate cancer at a stage when it is still potentially curable. PSA screening saves the lives of thousands of men every year. Radical prostatectomy, external beam radiation therapy (IG-IMRT) and brachytherapy (seed implantation) continue to improve. Side effects are falling and cure rates rising.
For example, in the medical journal Cancer in 2011, I published a 99.1% cancer-free survival rate with brachytherapy +/- IMRT. Other experts are publishing similar numbers. We are making major strides in beating this disease. PSA screening needs to continue; otherwise we could be put back to where we were 30 years ago. To learn more or to schedule an appointment, please contact Lakewood Ranch Oncology Center at 941-907-9053 or visit us online at www.LWROncology.com.