Surgery and PSA Testing
Since the United States Preventive Services Task Force (USPSTF) announced their decision about the lack of benefit derived from PSA screening, there has been a huge controversy surrounding this decision. If one were to believe the results of this task force, PSA testing would never be performed, and all men would never be affected by prostate cancer. That would all be well except for the fact that more than 25,000 men die annually from prostate cancer.
The task force recommendations have definitely resulted in fewer men undergoing PSA evaluations, which will lead to lower diagnosis and subsequently treatment rates for prostate cancer. These recommendations against PSA-based screenings for prostate cancer was made for all men, regardless of risk. Some of the studies that the task force utilized to make their recommendation suggested that early intervention in prostate cancer did not have any bearing on the outcome of these patients. At the time of their decision, other clinical studies were available that suggested that there were benefits that could be derived if early intervention were to be undertaken.
Recently, a new study was published in the New England Journal of Medicine (NEJM; 270:10) that reviewed the outcomes of 695 patients who underwent either surveillance or surgical intervention in the Scandinavian Prostate Cancer Study Number 4. The findings of this study revealed that with longer-term follow-up (23 years) there was a significant reduction in prostate cancer mortality after radical prostatectomy. The benefits that were reported in the group of patients who underwent surgery was greatest in patients less than 65 years of age; however, spread of disease to distant locations was also reduced in patients over the age of 65 who underwent surgery. One additional significant finding was that patients, who underwent surgery, were less likely to require additional hormone therapy in the future. Every third man during the study period who was assigned to a course of surveillance died from prostate cancer or other causes, but usually with metastasis having occurred, compared to every fifth man in the surgery group.
This recent finding is substantially different than the findings that were reported in the Prostate Cancer Intervention versus Observation Trial (PIVOT), which demonstrated that surgery did not significantly reduce prostate cancer mortality after 12 years. The data that was presented in the PIVOT was part of the data that the USPSTF used to generate their adverse decision on prostate cancer.
This recent study and other ongoing studies need to be considered and discussed with you Urologist and primary care physician when it comes time to obtain a PSA. Perhaps even more important is that these new findings should be seriously contemplated in those who have been diagnosed with prostate cancer and who may be considering a course of surveillance.
With the new study identifying additional benefit with the use of intervention, it is time for the task force to once again study this. Although PSA testing does have some drawbacks, it is the only test that we presently have that helps us to diagnose prostate cancer. The task force is rather set in its ways, and getting them to re-evaluate PSA testing so quickly will be a daunting task.
Presently there is a bipartisan bill in the House of Representatives H.R. 2143, the USPSTF Transparency and Accountability Act of 2013 that specifically addresses the way that this task force reaches its decisions. This bill would include critical reforms that would require the USPSTF to: 1) publish research plans to guide its systematic review of evidence and new science relating to the effectiveness of preventive services; (2) make available reports on such evidence and recommendations for public comments; (3) codify the grading system so it cannot be changed without an appropriate review; and (4) establish a preventive services stakeholders board to advise it on developing, updating, publishing, and disseminating evince-based recommendations on the use of clinical preventive services. The bill would also ensure that Medicare or other payors couldn’t deny payment for a preventive service solely based on its Task Force Grade.
Prostaste cancer is a very serious health problem that affects thousands of men and their loved ones. We can not sit still while a government agency has not considered all the data that is available. I urge you to contact your representative to support H.R. 2143, the "USPSTF Transparency and Accountability Act of 2013" which will hopefully prevent decisions such as this from occurring in the future.
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.