UPDATE: In May 2012, the USPSTF finalized its recommendation against PSA-based screening for prostate cancer. To learn more, read the recommendation statement.
In the latest development in the ongoing PSA testing debate, the United States Preventive Services Task Force (USPSTF) has released a new draft recommendation that significantly changes the group’s guidance on the use of the PSA test to screen for prostate cancer. The task force discourages use of the test for healthy men in all age groups, saying that the harms outweigh the benefits and that testing does not reduce death rates. This recommendation is at odds with that of the American Urological Association and other major health organizations. Most groups maintain that PSA is useful and encourage men to discuss the issue with their doctors when deciding whether to be tested.
Prostate cancer is the second most common cancer in U.S. men after skin cancer, and is second only to lung cancer in the number of deaths it causes. About 240,000 new cases will be diagnosed in 2011, estimates the American Cancer Society, and about 34,000 men will die of the disease.
Though prostate cancer can be deadly, it is often slow-growing and a man may not know that he has it unless he has had prostate biopsies. Moreover, a man may not have prostate cancer even when elevated PSA levels are present. Such false-positive results can lead to unnecessary anxiety and painful biopsies. In some cases, biopsies find prostate cancers that may never cause problems and prompt some men to undergo needless treatments that can cause complications such as erectile dysfunction or urinary incontinence.
Therein lies the problem with PSA. It may be used to screen for prostate cancer, but it cannot tell if the cancer is aggressive or slow-growing. A man who has an elevated PSA test must decide with his doctor what, if any, follow-up testing or treatment should be done. Doctors and their patients often consider advice from health care organizations such as the USPSTF to help in the decision-making process, though the advice is not always clear-cut. Various experts can view the evidence differently and conclude with conflicting recommendations.
The most recent recommendation on prostate cancer from the USPSTF updates an earlier one from 2008, which said there was a lack of evidence to advise for or against screening with PSA in men younger than 75. The task force had already advised against screening men older than 75, saying these men were more likely to die from something other than prostate cancer. The new draft guidance was published on October 11 and will be available for public comment until November 8.
The USPSTF is a federally-funded panel of health professionals assembled for the purpose of reviewing available scientific evidence to develop guidance on a variety of preventive services, including testing individuals with no signs or symptoms for various diseases and conditions. In developing recommendations, it looks at how well screening benefits those tested without causing detrimental effects.
To update the guidelines on prostate cancer, the USPSTF examined evidence from numerous published studies. Some of the studies evaluated PSA screening while others looked specifically at benefits and harms of treatment. Two of the largest studies conducted over several years were the U.S. Prostate, Lung, Colon and Ovary cancer screening trial (PLCO) and the European Randomized Study of Screening for Prostate Cancer (ERSPC). (For more on these, see the article Prostate Cancer Screening Studies Don't Settle Question of Clinical Utility)
In evaluating the usefulness of PSA testing, the panel viewed the primary goal as reducing the number of deaths due this type of cancer. The available evidence on PSA shows that testing does not improve survival rates, says the USPSTF. Furthermore, the group asserts that while some lives may have been saved through testing, many more men have been adversely affected by false-positive results and the harms caused by unnecessary treatments.
The latest debate over PSA testing is not the only one embroiling the USPSTF in recent years. In November 2009, the group stirred controversy by not recommending annual breast cancer screening with mammography for women younger than 50 and by advising those 50 and older to have mammograms every other year. Several health organizations, including the American Cancer Society and the American College of Obstetricians and Gynecologists have endorsed recommendations in conflict with those from USPSTF, advising women to have mammograms yearly starting at age 40.
Though the USPSTF concluded through their review of studies that there is no value in screening with PSA, many physicians continue to support PSA testing. Some organizations, such as the American Cancer Society and the American College of Physicians, endorse informed counseling of men before deciding whether to screen while still others, such as the American Urological Association, are in favor of screening. Some groups argue that more research is needed to find a follow-up test to PSA that would determine which cancers are aggressive and will progress. Research is ongoing in that regard. (For more, see the article Researchers Study Possible New Marker for Prostate Cancer)
Meanwhile, men and their doctors are left to make sense of the conflicting messages on PSA. In the end, men should think about several factors in deciding whether to be screened. They must consider their age, their own relative risk for cancer, and what they would do if they tested positive. Men need to decide if they would rather know or not know if cancer is present and, if it is present, would they prefer to follow with watchful waiting (active surveillance) or be willing to take a more aggressive approach with treatment but risk complications and decreased quality of life.
In its draft guidance, the USPSTF states that "The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision-making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms."
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Conditions: Prostate Cancer
Screening: Adults, Adults 50+
News: PSA Velocity (PSAV) Leads to More Biopsies, Without Improving Prostate Cancer Detection, Study Finds (2011), Prostate Cancer Screening Studies Don't Settle Question of Clinical Utility (2009), Prostate Cancer: To Screen or Not to Screen? (2008)
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NOTE: This article is based on research that utilizes the sources cited here as well as the collective experience of the Lab Tests Online Editorial Review Board. This article is periodically reviewed by the Editorial Board and may be updated as a result of the review. Any new sources cited will be added to the list and distinguished from the original sources used.
United States Preventive Services Task Force. Screening for Prostate Cancer Draft Recommendations Statement (October 11, 2011). Available online at http://www.uspreventiveservicestaskforce.org/draftrec3.htm through http://www.uspreventiveservicestaskforce.org. Accessed October 13, 2011.
United States Preventive Services Task Force. Screening for Prostate Cancer, A Review of the Evidence (Released October 2011). Available online at http://www.uspreventiveservicestaskforce.org/uspstf12/prostate/prostateart.htm through http://www.uspreventiveservicestaskforce.org. Accessed October 13, 2011.
(Reviewed November 22, 2010) American Cancer Society. Detailed Guide on Prostate Cancer. Available online at http://www.cancer.org/Cancer/ProstateCancer/DetailedGuide/index through http://www.cancer.org. Accessed October 13, 2011.
(October 6, 2011) Charles Bankhead. Panel Says Prostate Test Does Not Save Lives. MedPage Today. Available online at http://www.medpagetoday.com/HematologyOncology/ProstateCancer/28929 through http://www.medpagetoday.com. Accessed October 12, 2001.
(October 7, 2011) Douglas Quenqua. Insurers Review Whether to Still Pay for Routing Screening. The New York Times. Available online at http://www.nytimes.com/2011/10/08/health/policy/08consumer.html?_r=3 through http://www.nytimes.com. Accessed October 13, 2011.