Will physicians still give patients PSA test?

Doctors are likely to be divided about whether to follow new guidelines recommending against PSA-based screening in asymptomatic men.

By — Posted Oct. 24, 2011

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Family physician Shailendra Saxena, MD, PhD, screens his middle-age male patients annually for prostate cancer using the prostate-specific antigen test. The screen, coupled with a digital rectal exam, has helped him detect prostate cancer.

"My patients have benefited a lot because of this," said Dr. Saxena, of Omaha, Neb.

As a result, he plans to continue regularly measuring PSA levels despite a new recommendation by the U.S. Preventive Services Task Force to abandon the screening test for asymptomatic men. Health professionals long have viewed the PSA test as the most reliable prostate cancer screening tool.

The task force is saying "don't do the PSA, but they're not telling [us] what to do" in its place, said Dr. Saxena, an associate professor in the Dept. of Family Medicine at Creighton University School of Medicine in Nebraska. "What other methods do we have," he asked, to more accurately detect prostate cancer?

In lieu of an answer, many physicians can be expected to continue giving it as a screening test.

On Oct. 7, the task force issued a draft recommendation statement against PSA-based screening for prostate cancer in men without symptoms of the disease. The expert panel did not evaluate the use of the PSA test in men with symptoms or its use for surveillance after diagnosis and/or treatment of prostate cancer.

The statement 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.

Health professionals and the public have until Nov. 8 to comment on the new proposal. Comments will be reviewed by the task force before the panel writes its final guidance.

Medical organizations, such as the American Urological Assn., and physicians have come out against the recommendation, calling it a disservice to men who might benefit from the test.

"PSA is the best screening test we have for prostate cancer, and until there is a replacement for PSA, it would be unconscionable to stop it," said prostate cancer surgeon William Catalona, MD, director of the Clinical Prostate Cancer Program at the Robert H. Lurie Comprehensive Cancer Center of Northwestern University in Chicago. Dr. Catalona is credited with being the first to show that the PSA test is the most accurate method for detecting prostate cancer.

The proposal conflicts with guidelines of some organizations, including the AUA and the American Cancer Society. That has left many primary care doctors uncertain of which screening guidelines to follow. And some physicians worry that adhering to the task force recommendation could increase their liability risk if they miss aggressive cancer in asymptomatic men.

Insufficient evidence

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 cancer society. The organization estimates there will be more than 240,000 new cases of prostate cancer diagnosed in 2011, and 33,720 men will die of the disease. (See correction)

The task force said there is insufficient evidence to prove that PSA screening prolongs lives. The panel examined studies on screening for asymptomatic men published between 2002 and 2011. It found that although screening based on PSA identifies prostate cancers, there is little to no reduction in mortality due to the disease after about 10 years.

But data indicate that screening asymptomatic men leads to the overdiagnosis and overtreatment of prostatic tumors that will not cause illness or death, according to the task force. As a result, men are exposed to unnecessary harms, including impotence, infection and urinary incontinence, the panel said.

During a 10-year period, up to 20% of men will have an abnormal PSA test result that triggers a biopsy, the task force said. Research shows that a biopsy causes a negative side effect in about 68 per 10,000 biopsies.

The task force concluded that the harms of PSA-based screening for prostate cancer outweigh the benefits. Panel members expected their findings to generate controversy among the medical community and public, said Michael LeFevre, MD, MSPH, co-vice chair of the task force.

"The belief that prostate cancer screening saves lives is certainly a common belief. Any time you take a belief and subject it to science, and science doesn't confirm what you believe, there's going to be a problem," he said.

New York internist Louis Papa, MD, however, considers the task force recommendation too aggressive, considering there are conflicting data from studies.

For example, a European study found that PSA screening every two to seven years was associated with a 20% relative reduction in risk of prostate cancer death in men age 55 to 69, said a review of the task force's evidence published online Oct. 7 in Annals of Internal Medicine. A large U.S. study, on the other hand, found that screening had no effect on death related to the disease.

The recommendation "really raises a lot of concern in my mind about the future of PSA screening and how we're going to have this discussion with patients" about why we no longer are screening them regularly, said Dr. Papa, a professor of clinical medicine at the University of Rochester Medical Center.

For years, men 50 and older have been told by health professionals that an annual PSA could save lives. "Once you start doing something with patients, it's very hard to stop doing it," Dr. Papa said.

Educating patients

In light of the task force recommendation, Joseph Stubbs, MD, plans to take more time educating his male patients about the possible complications that can occur after an abnormal PSA test. Rather than routinely screen all men 50 and older, the Albany, Ga., internist said he will let them decide if they want the test.

He said he will tell patients, "Part of your annual checkup in the past has been a PSA test, but some studies and an expert panel say we need to talk about this more, because there might be more harm than good done with this test."

When discussing the need for screening with patients, physicians should consider prostate cancer risk factors, such as age, race and having a father or brother diagnosed with the disease before age 65, said Dr. Stubbs, past president of the American College of Physicians.

He also urges doctors to look for symptoms that can indicate prostate cancer, including sudden back pain, more urinary urgency, burning during urination and blood in the urine. He said these patients should be screened for the disease.

The American Medical Association recommends that physicians educate men who are interested in prostate cancer treatment about their risk of developing the disease and the potential benefits and harms of screening.

Urologist Richard E. Greenberg, MD, does not plan to follow the task force guideline, because he has seen the benefits of screening PSA levels in men with no symptoms.

"Missing an early aggressive cancer in a young man because [the biopsy] might be negative is wrong," said Dr. Greenberg, chief of urologic oncology at Fox Chase Cancer Center in Philadelphia.

Susan Pisano, a spokeswoman for America's Health Insurance Plans, said it isn't clear how the guideline would affect insurance coverage. But she said health insurers historically have relied heavily on task force recommendations when determining coverage of procedures.

Whatever insurers and doctors decide to do, getting patients to understand and accept the recommendation will take time, Dr. Stubbs said.

"For men, the PSA is their mammogram. They want it. They mistakenly think it helps prevent prostate cancer."

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Prostate cancer screening

The U.S. Preventive Services Task Force issued a draft recommendation against prostate-specific antigen screening for prostate cancer in asymptomatic men. Here are screening guidelines of other medical organizations.

American Cancer Society

  • Discuss the risks and benefits of prostate cancer screening with asymptomatic men 50 and older who are expected to live at least 10 more years. The conversation should take place at age 45 for men at high risk of developing the disease and at 40 for men with multiple first-degree relatives who had prostate cancer.
  • Men who want to be screened should be tested with the prostate-specific antigen blood test.
  • For men who are unable to decide, the screening decision should be left to the health professional.
  • Retest men every two years who have a PSA of less than 2.5 ng/mL.
  • Annually screen patients whose PSA level is 2.5 ng/mL or higher.

American Urological Assn.

  • Discuss the risks and benefits of prostate cancer screening with asymptomatic men 40 and older who have a life expectancy of at least 10 years.
  • Men who want to be screened should be tested with the prostate-specific antigen blood test and a digital rectal examination.
  • The decision to perform a prostate biopsy should be based on PSA and DRE results, the individual's age, family history, ethnicity, PSA velocity, and free and total PSA levels, among other factors.

Source: American Cancer Society, American Urological Assn.

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External links

Screening for Prostate Cancer: U.S. Preventive Services Task Force draft recommendation statement, Oct. 7 (link)

"Screening for Prostate Cancer: A Review of the Evidence for the U.S. Preventive Services Task Force," Annals of Internal Medicine, Oct. 7 (link)

Opportunity for public comment on the draft recommendation statement on screening for prostate cancer, U.S. Preventive Services Task Force (link)

Centers for Disease Control and Prevention on prostate cancer (link)

American Cancer Society on prostate cancer (link)

American Cancer Society recommendations for prostate cancer early detection (link)

American Urological Assn. on early detection of prostate cancer (link)

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This article incorrectly reported how commonly prostate cancer is diagnosed in American men. The disease is the second-most common cancer among men, after nonmelanoma skin cancer. The information came from incorrect data on a Centers for Disease Control and Prevention web page.

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