In February 2013, when the U.S. Preventive Services Task Force (USPSTF) changed the contemporary recommendations for prostate cancer screening, they felt that there was convincing evidence that PSA-based screening programs resulted in the detection of many cases of asymptomatic prostate cancer. They also felt that there was convincing evidence that a large number of men who are detected with disease have a tumor that either will not progress and cause harm, or, if it were to progress, it would occur so slowly that it would remain asymptomatic.
The purpose of this post is not to refute the claim of the task force. There is clearly evidence that does not support their findings, and this has been a topic of much discussion amongst Urologists, Radiation Oncologists and Medical Oncologists and the debate will continue. Over the last year, how has this recommendation affected the way that prostate cancer is being diagnosed or treated in the U.S.? Most physicians who are involved in the treatment of prostate cancer have reported a decrease in the number of newly diagnosed cases since the new guidelines were released. In the office, far fewer biopsies are being performed. Radiation therapists have reported decreases in the number of patients who are undergoing treatment. More patients are now undergoing surveillance protocols instead of having active treatment. Discussions with primary care physicians have revealed that they are ordering fewer PSA tests.
Is this the best approach to the management of this disease? Are we now under-treating our patients which may result in a reversal of the trend migration that we noted in the early 90's which will essentially have us once again see more patients presenting with advanced disease over time? This less aggressive approach to the diagnosis and the treatment of this disease would make complete sense if indeed nobody ever succumbs to prostate cancer. However, this is not the case, as every year patients do die from this disease. Many patients also present with metastatic disease after having never undergone screenings.
Despite the guidelines being in place, I advocate a thorough discussion with my patients about the virtues and drawbacks to undergoing a PSA test. If it is decided that a PSA will be obtained, the results of this should not result in a knee-jerk response that the patient needs to be treated. Clearly, there are patients who are going to benefit by having their prostate cancer treated. It should not be our responsibility to ignore these patients and not test them. It is our responsibility to test these patients and assess the results.
In those that cancer is detected, it is imperative that a thorough discussion occur that systematically reviews the alternatives, risks and benefits of all therapies. This discussion needs to include both non-invasive options which active surveillance should be included, minimally invasive treatments such as radiation therapy, cryotherapy, and HIFU, as well as traditional surgical intervention. An ounce of knowledge is worth a pound of cure.
Without providing our patients with as much information as possible about their disease state we are doing them a disservice. If an elevated PSA results in a prostate biospy that reveals prostate cancer, is this a bad thing for the patient? I do not think so provided that practitioners do the responsible things with that information. This should include an extensive discussion regarding all treatment options, the risks and benefits associated with these treatments and not automatically do the knee-jerk response and indicate the patient for radical surgery.