#psa screening

Prostate Cancer News: PSA screening significantly reduces the risk for death

After differences in implementation and settings were accounted for, two important prostate cancer screening trials provide compatible evidence that screening reduces prostate cancer mortality.

After differences in implementation and settings were accounted for, two important prostate cancer screening trials provide compatible evidence that screening reduces prostate cancer mortality. These…

My patient looked back at me with a blank stare. I had just finished my take on the pros and cons of having a PSA test, and he looked lost. “What would you do if you were me, Doc?” he said.

I had just finished explaining the decision every man faces when he turns 50: whether to be screened for prostate cancer with a prostate-specific antigen (PSA) test. The decision is still unsettled despite the results of a giant, long-term study published earlier this month in the journal The Lancet. The study did not support the use of widespread screening.

What makes the decision so tricky? It’s partly that prostate cancer is a weird cancer. Unlike cancer of the breast or the lung or the colon, which tends to kill people within five or 10 years, prostate cancer is usually slow growing. Men tend to die with it rather than of it. In fact, many live with it for 30 years or more and never even know they have it.

By Dr. John Sylvester

There has been a great deal of attention in the media recently about PSA screening. A few months ago, the United States Preventative Services Task Force (USPSTF) came out with preliminary recommendations that PSA screening should not be done. They have now decided to make this decision final. 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 are 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 will longer follow-up now shows a 31% reduction in prostate 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 positive studies was, again, not explained.

During the PSA era, prostate cancer mortality in the USA had dropped ~40% 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 antibiotic may make the PSA fall, in which case a biopsy may not be needed.

Even 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 Modulate Radiation Therapy (IG-IMRT), Radioactive seend 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.