Task force recommends against PSA test for prostate cancer

New guidance urging physicians to stop using the prostate-specific antigen test to screen men of any age for prostate cancer has raised objections among some doctors and at least one medical organization.

The recommendation, issued May 21 by the U.S. Preventive Services Task Force, says the small potential benefit of PSA screening in asymptomatic patients does not outweigh the expected harms of biopsies and treatment for cancerous tumors that often are slow-growing and not life-threatening. Such problems include fever, bleeding and infection from biopsies and urinary incontinence and erectile dysfunction due to radiotherapy and surgery, the task force said.

The guidance does not apply to men who have been diagnosed with prostate cancer or those being treated for the disease.

Some critics worry that the recommendation could cause health insurers to stop covering the test for men who still want it, causing prostate cancer deaths to increase.

The task force released a draft recommendation on Oct. 7, 2011, and said it received about 3,000 comments from health professionals and the public. No changes were made for the final recommendation, which was published online May 21 in Annals of Internal Medicine(link).This latest guidance updates the 2008 task force recommendation that said there was insufficient evidence to determine whether PSA-based screening should be conducted on men younger than 75. The change from 2008 was driven, in part, by recent data showing that although PSA-based screening identifies prostate cancers, there is, at most, a small reduction in mortality due to the disease after 10 to 14 years, the task force said.

“It is important for doctors and patients to understand that our current approach to screening for prostate cancer does not serve men well,” said task force chair Virginia Moyer, MD, MPH.

“There is a critical need for a better test — one that leads to early detection of cancers that threaten men’s health, but minimizes unnecessary, risky tests and treatments that do not lead to longer or more healthful lives,” said Dr. Moyer, professor of pediatrics at Baylor College of Medicine in Houston.

The American Urological Assn. said the task force undermined the validity of PSA-based screening in saving the lives of men at risk of developing prostate cancer.

“It is inappropriate and irresponsible to issue a blanket statement against PSA testing, particularly for at-risk populations, such as African-American men,” said former AUA President Sushil S. Lacy, MD.

The AUA recommends that physicians offer a PSA test and a digital rectal exam to asymptomatic men 40 and older who want to be screened and who have a life expectancy of more than 10 years.

Some health professionals say that until a better test is identified, the PSA screen is the tool doctors have to detect prostate cancer early and enhance the chance of survival for those who have the condition.

“What they’ve done is really extreme. It’s misguided & and it’s not warranted,” said prostate cancer surgeon William J. Catalona, MD, director of the Clinical Prostate Cancer Program at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University in Chicago. He is credited with being the first to show that the PSA test is the most accurate method for detecting prostate cancer. Dr. Catalona co-wrote an editorial on the task force’s recommendation that was published online May 21 in Annals (link).

Does screening lead to overdiagnosis?

Prostate cancer is the second most commonly diagnosed cancer among U.S. men and remains the second-leading cause of cancer death in men after lung cancer, according to the American Cancer Society. The organization estimates that there will be 241,740 new cases of prostate cancer diagnosed in 2012, and about 28,170 men will die of the disease. Seventy percent of those who die are older than 75, the task force said.

In making its recommendation, the task force examined recent studies on screening for asymptomatic men. Task force members found that screening asymptomatic men often leads to the overdiagnosis and overtreatment of prostatic tumors that will not cause illness or death.

“Many more men in a screened population will experience the harms of screening and treatment of screen-detected disease than will experience the benefit,” the panel wrote.

The task force acknowledges that some patients will continue to request PSA screening and that some physicians will offer the test. In those cases, the task force encourages doctors to discuss with patients the potential benefits and harms of PSA screening and help them make a decision.

The cancer society supports the updated guidance, said Otis W. Brawley, MD, the group’s chief medical officer. The ACS recommends that men, starting at age 50, have the opportunity to make an informed decision with their physician about whether to be screened for prostate cancer. Dr. Brawley wrote an editorial on the latest task force guidance that was published online May 21 in Annals(link).

“I advise that doctors read the [task force] evidence themselves. Realize what we know and what we don’t know. The one thing we know are the harms of prostate cancer screening are significant,” Dr. Brawley said.

“What we don’t know is does prostate cancer screening save lives.”