The PSA debate. What am I telling my patients?

I’ve posted several blogs on the raging debate about the US Preventive Services Task Force’s (USPSTF) recommendation concerning the PSA (prostate specific antigen) blood test and screening for prostate cancer. Now, after much study and prayer, let me share what I’ll be telling my patients.

The bottom line is that this government panel says that healthy men should no longer be routinely screened for prostate cancer. Not only do they say they aren’t certain whether a man should get a PSA test to find prostate cancer early, they came flat out and said, effectively, “Don’t do it!”

Why? They say that for any group of male patients “the PSA blood test generally results in more harm than good.”

The panel’s review, published in the Annals of Internal Medicine, “identified five clinical trials that sought to assess whether men who got routine PSA tests were less likely to die of prostate cancer than those who did not get the testing.” Three trials were too flawed, although NONE of them found benefits. The remaining two also found NO benefit.

Nevertheless, some say there can be a compromise, such as recommending “regular screening only for those at high risk for the disease.”

The Task Force chair, Virginia A. Moyer, wrote a very nice opinion piece for USA Today about “the limitations of PSA screening.” Moyer points out that if PSA testing had “significant benefit, it should have been apparent by now, and it is not.”

USA Today notes in another opinion piece “the furor of doctors, including the American Urological Association,” and says that the side effects of biopsies and treatments are still “a lot better than being dead.”

Unfortunately, it is just such scaremongering that got us into this mess in the first place (you can read more about this approach to trying to scare men into procedure here or here).

So, after much study, discussion with peers, and prayer, here’s what I’ve decided to to tell my patients who are at LOW risk for prostate cancer:

  • There are TWO screening tests for prostate cancer: the digital rectal exam and a blood test called the PSA test.
  • The US Preventive Services Taskforce (USPSTF) recommends AGAINST these services. They say, “There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.” They tell us doctors to “Discourage the use of this service.”
  • The Task Force is on record as recommending that men NOT get PSA testing. They conclude there is no real proof of benefit, and real proof of harms. Too many men go through too many treatments with too many long -lasting complications without a clear expectation that it will save their lives.
  • However, the American Urologic Association says, “The PSA test provides important information in the diagnosis, pre-treatment staging or risk assessment and monitoring of prostate cancer patients. But not all prostate cancers are life threatening. The decision to proceed to active treatment or use surveillance for a patient’s prostate cancer is one that men should discuss in detail with their urologists.”
  • In the middle of the road is the American Cancer Society. The ACS says to men, in essence, that it does not know whether or not PSA testing saves lives. It thinks the best approach is for men and their health professionals to have a clear discussion, outlining the benefits and risks before embarking on a program of PSA testing. And that remains their recommendation today.
  • It’s obvious that there are potential benefits and risks to this testing … but at this point it appears the RISKS OUTWEIGH ANY BENEFITS.
  • So, if you decide you want the tests (PSA AND DRE), I’m happy to refer you to a urologist who will most likely be willing to do both for you on a yearly basis.
  • I’m NO LONGER recommending or DOING the tests.
  • Why not? Because if I do them it’s much more likely that I’ll do harm than good for those men who come to me for my care and advice.
  • But I will refer you for them at YOUR REQUEST.
  • If both tests are normal, they can be very reassuring.
  • However, if one or both tests are abnormal, you WILL face a variety of difficult decisions which you can discuss with the urologist.
  • Whatever you choose, I’ll walk with you through the entire process.
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