PSA Testing and New Guidelines Create More Confusion
By now you must really be confused by prostate cancer. To be honest, many urologists are also confused. Let me review some of the facts with you. Prostate cancer will affect one of six men during their lifetime. The American Cancer Society estimates that in 2013, about 240,000 new cases of prostate cancer will be diagnosed. An estimated 29,720 men will die of prostate cancer. Prostate cancer is the second leading cause of cancer death in the U.S., only behind lung cancer. So why is there such a conundrum about this disease?
Much of the indecision that surrounds the treatment of prostate cancer has arisen since the United States Preventive Services Task Force’s (USPSTF) gave the PSA test - a prostate cancer screening method - a D grade, concluding that the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than 75. In short, the USPSTF is unsure if there is much value in the PSA test for men under 75. The findings of this commission have been the subject of a great debate.
In response to this statement, the American Urological Association (AUA) has been looking into the validity of the task force’s recommendation. At its recent national meeting, the AUA issued its revised guidelines for the use of PSA testing. Perhaps this has even muddied the waters more. Despite what the tabloids and the press have reported and misinterpreted, the AUA has NOT recommended the abandonment of PSA testing. Despite its imperfections, at the present time, there is still no better means to determine if one has this potentially deadly disease. The new guidelines emphasize the need for transparency with regards to discussions that need to be had between patients and their physicians, thus individualizing patient care.
What also needs to be emphasized at this time is that the current guidelines do not make any changes for patients who are at high risk, those with a family history or African-American males. Patients who have certain lower urinary tract symptoms or an abnormal digital rectal examination results may also be considered to be in need of screening.
The new recommendations from the AUA recommend against PSA screening in men under age 40 due to a low prevalence of detectable prostate cancer and no evidence demonstrating the benefits of screening. For men ages 55 to 69, the guidelines state that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality. The guidelines evaluate mortality in 1 man for every 1000 men screened over a decade against the known potential harms associated with screening and treatment. As a result of this, the panel strongly recommends shared decision-making for men in this age group, and to proceed with treatment based on the patient’s values and preferences.
The panel does identify that the greatest benefit of the PSA test does exist in patients ages 55 to 69. To reduce the potential harms of screening, a routine screening interval of two years versus yearly screening is recommended for those men who have participated in shared decision-making and decided to be screened. It is expected that this interval will preserve the majority of the benefits of screening and reduce over-diagnosis and false positive results. Intervals can also be determined after a baseline PSA has been obtained. Lastly, the panel does not recommend routine PSA screening in men over age 70 or those with less than a 10- to 15-year life expectancy.
Now I am sure that you must fully understand this To make matters even worse, I will point out that these recommendations from the USPSTF were not based on morbidity, complications that arise with the development of advanced prostate cancer, but only on deaths that would be averted with the use of this testing. Patients fear the side effects of metastatic disease that accompanies advanced prostate cancer. PSA testing has also been associated with a decrease in PSA mortality since its use became widespread.
There are clearly some benefits associated with using PSA testing; however when used incorrectly, the benefits of testing may be outweighed. Until further tests are developed or the use of genomic testing (tests that possibly better stratify those patients who have high risk disease and could greatly benefit from treatment) becomes more of an exact science, we only have PSA testing to rely upon. Patients do not want to risk becoming one of the nearly 30,000 patients who succumb to this disease this year.
With this in mind, the best recommendation that can be made is for you to discuss this in great detail with your urologist and determine if PSA testing is right for you.
Jay Motola, MD, is a board-certified urologist and attending physician, Department of Urology, Mount Sinai West, and Assistant Professor of Urology, Icahn School of Medicine at Mount Sinai. Dr. Motola is a summa cum laude, Phi Beta Kappa graduate of Boston University, and earned his medical degree at the State University of New York at Stony Brook.