The PSA test seems fairly straight-forward. So why should there be a controversy?
Having been involved in urology prior to the widespread use of PSA testing, I and many other urologists have unfortunately spent time on the wards of hospitals that had numerous patients who were hospitalized as a result of the side effects of advanced prostate cancer. In my opinion, this simple blood test has resulted in countless numbers of patients who have been spared the terrible side effects of the disease - including bone pain that occurs as a result of metastatic disease and renal failure as a result of ureteral obstruction. The appropriate use of this test has resulted in the earlier diagnosis of this disease and prevented advanced disease from occurring.
Now for the controversy: recently the United State Preventive Services Task Force (USPTFS) issued a draft report on PSA screening for the detection of prostate cancer. This report resulted in it being giving a “D” grade. This grade indicated that “there is a moderate or high certainty that the test has no net benefit or that the harms of testing outweighs the benefits,” and “it recommends against the service.” This task force is comprised of primary care physicians such as internists, pediatricians, family physicians, gynecologists/obstetricians, and nurses who have expertise in prevention, evidence-based medicine and primary care. But do any of these physicians have any expertise in taking care of patients who have been ravaged by the complications of prostate cancer? If you were diagnosed with prostate cancer, would you run to a gynecologist or pediatrician for help in managing the disease? Don’t we think that the inclusion of an expert in this disease process be included in the decision-making process? Why wouldn’t a urologist, radiation therapist or radiation oncologist be included?
By giving the test a D grade, and if the grade remains unchanged, it would be the responsibility of the physician to discourage the use of this test. However, if this committee were to reevaluate their decision and change the PSA evaluation to a C grade, patients will then be involved in the decision making process to determine if they wanted to do the test or not. I believe that the benefits of this test should be determined individually by patients and not be a government agency.
Is knowledge better than ignorance? PSA testing is the best means that we now have available to identify those patients who may be at risk for harboring prostate cancer. After a prostate biopsy is complete, and if the biopsy identifies cancer, a patient must decide whether to treat the disease or to observe the disease. To make such a decision, the patient needs to be completely informed of their disease status.
Observation for prostate cancer is a suitable alternative for patients to consider. However, without complete knowledge of the disease process, a patient cannot adequately determine if this is the correct path to go down. The only way to have a total understanding of the disease state is with a biopsy. The goals of the USPTFS should be to encourage the appropriate use of PSA testing, the appropriate use of biopsy, and the appropriate treatments.