Prostate Cancer: How Useful is PSA Screening?
After reviewing thousands of studies, the U.S. Preventive Services Task Force Report on the Screening of Prostate Cancer was highly critical of the dependence on PSA testing for prostate cancer screening. The study concluded PSA screening and the resulting treatment can do more harm than good, and doesn’t prevent deaths from prostate cancer. The report was published in the scientific journal, The Annals of Internal Medicine last year.
“A high PSA test does not mean a man has prostate cancer or is at very high risk of developing it…The large majority of men with an elevated PSA blood test do NOT have prostate cancer,” said Timothy Wilt, a taskforce member and professor of medicine at the Minneapolis VA Center for Chronic Disease Outcomes Research “Science now shows us that screening for prostate cancer with the PSA blood test is very unlikely to help men live longer or prevent prostate cancer death,” said Wilt.
“In addition, PSA testing leads to considerable harms not only with the blood tests but with downstream consequence of testing. This is true even in the group of men (ages 55-69) who may be at greatest possible benefit,” added Wilt.
A Personal Story
This report concerns me as recently, men in my life went through prostate cancer scares. Their experiences led me to investigate the real story behind prostate cancer’s prevention and treatment protocols. I was surprised to find that these men, and many like them, were needlessly exposed to life-threatening procedures and lived with their miserable consequences simply because of a higher than usual PSA test.
The saddest story is of my 80-year-old friend, John, who went through a prostatectomy. He was dead a few years later from heart failure, but after the prostate cancer surgery, his psychological and physical health rapidly deteriorated; his last years were pure misery, plagued by incontinence and impotence caused by (unnecessary?) prostate surgery. In the second case, my 60-year-old friend Mark was found with a higher PSA level than usual this year. He went through a biopsy – which found no cancer. He and his family were frightened, then relieved. My other 59-year-old friend, David, went through a biopsy last year because of a higher than usual PSA, with a finding of no cancer, but with complications from the biopsy. A year later, David’s PSA was back down to his usual level.
Did Mark or David need to be exposed to the dangers of a biopsy because of a higher than usual PSA? Should John have been advised to take such extreme measures during his final years? Probably not, according to the U.S. Preventive Services Task Force Report on the Screening of Prostate Cancer.
Task Force Analysis and Recommendations
“Prostate biopsies result in serious harms in about 1 in 3 men including: pain, fever, bleeding, infection, transient urinary difficulties, and need for hospitalization,” said Wilt, task force member and co-author of a follow-up study, “Long Term Harms After Treatment for Prostate Cancer,” in the January 2013 British Medical Journal.
The task force reported: “Convincing evidence demonstrates that the PSA test often produces false-positive results (approximately 80% of positive PSA test results are false-positive when cutoffs between 2.5 and 4.0 μg/L are used) (4). There is adequate evidence that false-positive PSA test results are associated with negative psychological effects, including persistent worry about prostate cancer. Men who have a false-positive test result are more likely to have additional testing, including 1 or more biopsies, in the following year than those who have a negative test result (5). Over 10 years, approximately 15% to 20% of men will have a PSA test result that triggers a biopsy, depending on the PSA threshold and testing interval used (4). New evidence from a randomized trial of treatment of screen-detected cancer indicates that roughly one third of men who have prostate biopsy experience pain, fever, bleeding, infection, transient urinary difficulties, or other issues requiring clinician follow-up that the men consider a ‘moderate or major problem’; approximately 1% require hospitalization (6).”
“Periodic digital rectal examinations could also be an alternative strategy worthy of further study. In the only randomized trial demonstrating a mortality reduction from radical prostatectomy for clinically localized cancer, a high percentage of men had palpable cancer (17). All of these approaches require additional research to better elucidate their merits and pitfalls and more clearly define an approach to the diagnosis and management of prostate cancer that optimizes the benefits while minimizing the harms.”
“Older age is the strongest risk factor for the development of prostate cancer,” and while most men have prostate cancer, they rarely die from it.
“The Task Force recommendations provide up to date high-value, science-based health care recommendations, encourage patients and providers to know the facts, and choose wisely,” said Wilt. “I discuss these recommendations with confidence with my patients knowing it helps provide them with optimal patient-centered, science-directed health care. No major health organization recommends PSA testing. At best PSA testing results in a small benefit for a few but all are subject to testing and possible treatment harms.”
“While the task force did not consider cost, PSA testing and subsequent treatment are expensive, cost ineffective, low value care, according to an American College of Physicians recommendation,” said Wilt.
Solutions From the Task Force
“We must do better. We need better tests, more effective and less harmful treatments, and more selective use of current options. In the case of PSA testing and treatment for prostate cancer, less testing and treatment results in better health outcomes, and lower costs, a winning combination,” said Wilt.
“One approach for men and their physicians still wanting PSA testing would be to test PSA less frequently – every 2 to 4 years – rather than every year, and not to begin testing until age 55. Also, stop testing in men with a life expectancy less than 15-20 years (age 70 or earlier if with serious other medical conditions) and to raise PSA levels that define abnormal, for instance, from 3 or 4 to approximately 8 to 10,” said the Task Force.
“Other suggested but not proven strategies are to evaluate abnormal PSA values with noninvasive tests like a special type of MRI looking for ‘hot spots’ to biopsy that may be more likely to signal aggressive cancers and if absent hopefully avoid unnecessary biopsies, detection and treatment of “low risk” disease (these men comprise 60-80% of men currently diagnosed). Treatment harms include: immediate risks of surgery or radiation and longer term bowel, urinary and sexual dysfunction. Therefore for most men choosing not to have the PSA blood test …and choosing observation rather than early treatment if detected with PSA testing is a wise health care choice,” said Wilt, based on the report results. “Health care providers should convey and support this information. We need better tests and treatment options and wiser use of available methods.Genetic testing is not of proven value yet,” said Wilt.
“We could also work to try and not label ‘low risk disease’ as cancer because it has a very benign long term natural history but doctors and patients fear cancer and treat almost all aggressively resulting in harm without benefit,” said Wilt.
“In addition, despite evidence that more expensive ‘advanced’ therapies (robot surgery, IMRT or photon raidotherapy) are not more effective or safer than traditional therapies or observation – especially for low risk disease – new research shows they are increasingly used and very profitable-thus driving up the cost of care to patients and society without benefit,” added Wilt.
Obviously, more research into prostate cancer screening is needed to help men make the best decisions about their health. Learn more about prevention through diet and lifestyle!
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