The PSA Controversy: A view from family physicians.

The U.S. Preventive Services Task Force, or USPSTF, has once again rejected the status quo, following the evidence to propose a recommendation some likely will find controversial. Here’s a viewpoint from the American Academy of Family Physicians (AAFP) that I find very convincing:

The task force has published draft recommendations against prostate-specific antigen-, or PSA-, based screening for prostate cancer in asymptomatic men. The USPSTF gave the guidance a D recommendation, which means there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits, and the task force discourages use of the service.

The recommendation was made based on an evidence review of more than 60 trials and studies that specifically involved PSA-based screening or assessed the harms and benefits of prostate cancer treatment.

“At this point, we have no good evidence that PSA-based prostate cancer screening does any good, though we hold out hope there may be a small benefit,” said USPSTF Co-vice Chair Michael LeFevre, M.D., M.S.P.H., who added that roughly 75 percent of U.S. men older than age 50 have had at least one PSA-based screening. “But the harms are at least moderate.”

The task force was at the center of a controversy two years ago when it recommended a shift from annual to biennial screening mammography in women ages 50-74. It also recommended against routine screening mammography for women ages 40-49 who aren’t at increased risk for breast cancer, saying women in the latter age group should make a personal decision about screening based on a discussion with their doctor.

Since those recommendations were released, the USPSTF has altered its recommendation process to include a public comment period. The AAFP’s Commission on Health of the Public and Science is reviewing the prostate cancer screening recommendation and plans to provide feedback during the comment period.

“The AAFP has a high regard for the rigorous process used by the USPSTF and rarely disagrees with its analysis and recommendations,” said Herbert Young, M.D., director of the AAFP’s Health of the Public and Science Division and the staff executive for the commission.

In 2008, the USPSTF recommended against screening for prostate cancer in men age 75 years or older and concluded that evidence was insufficient to assess the balance of benefits and harms of screening men younger than 75.

LeFevre, who publicly questioned the value of PSA-based screening more than a dozen years ago, told AAFP News Nowthat more than 300,000 men have been enrolled in randomized screening trials in nine countries and, after 10 years of follow-up, “the hoped-for benefit is not apparent.”

LeFevre is professor and assistant chair in the department of family and community medicine at the University of Missouri, Columbia. He said that for every 1,000 men treated for prostate cancer, five die of perioperative complications; 10-70 suffer significant complications but survive; and 200-300 suffer long-term problems, including urinary incontinence, impotence or both.

“That’s a lot of harm for a cancer that didn’t need to be treated in the first place,” he said.

The task force acknowledged in its recommendation that there is convincing evidence that PSA-based screening results in the detection of many cases of asymptomatic prostate cancer.

However, the USPSTF noted, the majority of men who have asymptomatic cancer detected by PSA screening have a tumor that meets histological criteria for prostate cancer, but that tumor either will not progress or is so indolent and slow-growing that it will not affect the men’s lifespans or cause adverse health effects because the men are likely to die of other causes first.

“The evidence is convincing that for men aged 70 years and older, screening has no mortality benefit,” the task force wrote. “For men aged 50 to 69 years, the evidence is convincing that the reduction in prostate cancer mortality 10 years after screening is small to none. … Ninety-five percent of men with PSA-detected cancer who are followed for 12 years do not die from that cancer, even in the absence of definitive treatment.”

LeFevre said the recommendation likely won’t stop some physicians from offering screening, and it won’t stop some patients for asking for it.

“While the USPSTF discourages screening tests for which the benefit does not outweigh the harms, we certainly understand this test is in wide use,” he said. “If an individual man asks me for it, I’ll respond with a balanced discussion about what we don’t know, which is whether there is there is any benefit, and what we do know, which is that there are significant harms. I’ll still order the test if a man who knows the evidence says he still wants it.”

In its draft recommendation, the USPSTF called for additional research in a number of areas related to prostate cancer screening, including the need for a comparison of the long-term benefits and harms of immediate treatment versus observation with delayed intervention. The task force said that 90 percent of men with PSA-detected prostate cancer seek treatment, which typically involves surgery or radiotherapy.

The American Urological Association, or AUA, which supports the use of the PSA test, said in a statement that it is in the process of developing a new clinical guideline for prostate cancer screening. The AUA said its panel will review the use of the PSA test, early detection of prostate cancer, and new tests and diagnostics.

 

One thought on “The PSA Controversy: A view from family physicians.

  • Sharon Karela

    Every year my husband (and I) just dreads the thought of his having another PSA. He’s all ready had 2 biopsies starting from the time his numbers were high because he had an undetected infection My husband has had infections previous to PSA screening and, of course, needed another biopsy. This test is horrible. His doctor said not to have any caffine, flax or green tea since these things made the numbers high. How goofy is this? Thanks Dr. Walt for the info.

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