Panel: Don't Get PSA Prostate Cancer Screen
Harm Outweighs Benefit of Routine Prostate Cancer Screening, Task Force Says
By Daniel J. DeNoon
WebMD Health News
Reviewed By Laura J. Martin, MD
The European study dubbed the ERSPC found that a man's odds of dying of prostate cancer are 21% lower if he's offered routine PSA screening. Overall, one cancer death was prevented for every 936 men screened.
The large U.S. clinical trial dubbed the PLCO found that screened men tended to be more likely to die of prostate cancer. That's probably a statistical blip, as the test isn't likely to cause cancer deaths. But it does make it clear that the study found no indication of a benefit, LeFevre says.
Taking the two trials together, the USPSTF concluded that PSA screening simply doesn't prevent enough cancer deaths to make it worth the harms of unnecessary treatments.
Critics take a different view. They note that about half the supposedly unscreened men in the U.S. study actually had one or more lifetime PSA tests. That, they say, contaminates the results. Moreover, men in the study did not get prompt biopsies after a troubling PSA test.
"The bottom line is that the task force has made a recommendation against PSA screening based primarily on data from the U.S. trial, which unfortunately is not reliable," D'Amico says.
PSA Test: Controversial Issues
Interpretation of clinical trials isn't the only issue critics take with the USPSTF recommendation:
- The critics say that prostate cancer deaths have dropped 40% since PSA screening began. But LeFevre notes that this decline began years before PSA testing caught on -- and that there have been similar declines over the same time period in cancers for which there are no screening tests. D'Amico says that since PSA screening, there's been an even steeper drop in prostate cancer deaths.
- The critics say that the clinical trials have followed men only for about 10 years, too little time to see the full benefit of screening. But LeFevre says that in 10 years there should at least be a clear signal that screening is saving lives -- as has been seen with screening for colon and breast cancer. D'Amico says there was indeed such a signal, but the USPSTF didn't get it.
- The critics say the task force should at least recommend PSA screening for men at higher risk of prostate cancer, particularly African-American men and men with a family history of prostate cancer. But LeFevre says there's no clear evidence that PSA screening actually saves lives in these populations.
The biggest disagreement, however, is over how to weigh the lives saved by PSA screening against the risks of giving harmful treatments to men whose prostate cancers would never have killed them.
"The side effects of treatment occur often, occur early, and persist for the rest of a man's life," LeFevre says. "There are harms associated with overdiagnosis and overtreatment. The amount of time one spends living with one of those complications is much greater in the screened group."
D'Amico sees it differently.
"It comes down to the relative merit in a man's mind of having urinary incontinence which you can fix with a sphincter, or impotence for which you can get an implant; or having prostate cancer spread to the bone, riddling you with pain and taking your life," he says.
PSA Test: What Men Should Do
While the USPSTF recommends against routine PSA testing, it doesn't say that men should never opt for it.
The American Cancer Society likely will keep its recommendation that a man not get a PSA test until he has discussed the harms as well as the benefits with his doctor.
Many members of the American Urological Association feel strongly that men should seek the test. But the official AUA recommendation is very close to that of the American Cancer Society: They say men should discuss the benefits as well as the harms with their doctors.
The USPSTF recommendation raises the question of why so many U.S. men get PSA tests -- and why they are likely to continue doing so despite the new advice. Otis Brawley, MD, chief science officer at the American Cancer Society, suggests an answer in an editorial accompanying the USPSTF recommendation.
"Americans have been taught for decades to fear all cancer and that the best way to deal with cancer is to find it early and treat it aggressively," Brawley writes. "As a result, many have a blind faith in early detection of cancer and subsequent aggressive medical intervention whenever cancer is found. There is little appreciation of the harms that screening and medical interventions can cause."
Brawley makes a distinction between PSA tests given to men who fully understand both the harms and benefits and mass screenings "commonly conducted in shopping malls, churches, and community centers; at conventions and state fairs; and even in vans parked in grocery store parking lots."
And he notes that prostate screening is a lucrative business. The screening may be given away for free -- but biopsies and prostate cancer treatments reap profits for hospitals and clinics.
Catalona, W.J. Annals of Internal Medicine, May 21, 2012.
Brawley, O.W. Annals of Internal Medicine, May 21, 2012.
USPSTF Bulletin, May 21, 2012.
Michael LeFevre, MD, MSPH, USPSTF co-chair; professor and vice chair of family medicine, University of Missouri, Columbia.
Anthony D'Amico, MD, professor and chief of genitourinary radiation oncology, Brigham and Women's Hospital, Boston.
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