Stop Prostate Cancer Screening?

In 2011, the United States Preventative Services Task Force (USPSTF) made a recommendation to discontinue PSA screening.  This shocked the medical community responsible for treating prostate cancer, primarily the urologists and radiation therapists, who have passionately believed that early diagnosis and early treatment of prostate cancer saves lives. However, with radical prostatectomy rates continually spiraling, the USPSTF recognized that something needed to be done to slow the rush to unnecessary surgery and radiation.


So how big of an impact have the USPSTF recommendations made?  At the 2015 American Society of Clinical Oncology’s annual meeting, Dr. Scott Eggener from the University of Chicago reported that the USPSTF recommendations have clearly reduced prostate specific antigen (PSA) screening. Dr. Eggener used the National Health Interview Survey (NHIS), a nationally representative survey, to estimate the proportion of men screened for prostate cancer in 2010, prior to the recommendation, and compared it with the proportion of men screening in 2013 after the recommendation.  His study showed that screening has significantly declined from 2010 to 2013 among all men over 50. In his study he found that men between the ages of 60 and 74, the ones who were most heavily tested, underwent screening 51.2% of the time in 2010 compared to only 43.6% of the time in 2013.  In his study he also found that college-educated men had a even bigger decline in screening:  In 2010, 62.7% of college-educated men were screened compared to only 50.2% in 2013.


Other studies show that the decision to do PSA screening usually rests with the primary medical doctor (PMD) who either orders a PSA test or decides not to order one at the time of the annual physical examination. The results of Dr. Eggener’s study indicate that the PMDs appear to have taken to heart the USPSTF recommendations that PSA screening may be doing more harm than good.


One could argue the real problem with PSA is that it works too well, detecting very early forms of the disease in an elderly population years before we even need to know about it. This being the case, attention needs to be refocused on how primary care doctors respond to an elevated PSA rather than recommending the end of PSA testing altogether.

Presently, at the first sign of PSA elevation, the PMD typically refers the patient, to a urology specialist who usually arranges for an immediate 12-core random needle biopsy of the prostate through the rectum. More than a million men undergo this unpleasant procedure annually, risking the possibility of serious infections, bleeding and temporary impotence.

The bigger problem, however, is not the discomfort or the potential side effects of the biopsy.  The real issue is that more than 10% of the time grade six prostate cancer is detected.  In the past, Grade 6 prostate cancer was something we thought was potentially life threatening, but now we know it is essentially harmless and requires no treatment.

The problem is that whenever a patient hears the word “cancer”—unless he is intensively re-educated by a compassionate and patient doctor—radical surgery or radiation are the usual result.

Studies clearly show that the diagnosis of grade 6 disease often leads to unnecessary treatment, yet surgeons and radiation doctors seem to lack the patience to re-educate their patients. The safest thing to do with an elevated PSA is to order a multi-parametric MRI, rather than referring to a urologist. Well-performed scans can detect high-grade disease just as well as biopsy, but detect low-grade disease far less frequently.

The medical community needs to use the information PSA provides more judiciously. We can’t forget the fact that 30,000 men die annually from advanced prostate cancer, and this suffering is only the tip of the iceberg. There is an even larger number of men who don’t die, but suffer from the side effects of chemotherapy and hormonal treatment to keep them alive. Early diagnosis and treatment prevents an unnecessary death; it also reduces the number of men who need treatment for advanced disease.   

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