Clinician Insights

Physicians Continue to See Merits of PSA Testing

Alicia Ault

December 16, 2016

Although about two fifths of all of physicians (42%) in a recent Medscape poll said they believe the prostate specific antigen (PSA) test is overused, a huge majority (90%) said the benefits of the test always, often, or sometimes outweigh the risks, and many frequently recommend a baseline diagnostic for their male patients.

The poll results reflect the minefield that PSA testing has become in the wake of the US Preventive Services Task Force's 2012 recommendation against screening. The agency gave PSA testing a "D" rating.

Two studies subsequently published in JAMA in 2015 — one using data from the Surveillance, Epidemiology and End Results program, and the other using National Health Interview Survey data ― showed that prostate cancer screening using the PSA test had declined in the year after the USPSTF recommendation. At the time, the authors said it wasn't clear whether the decrease in screening had contributed to more cancers being missed or a rise in mortality.

A more recent study published in JAMA Surgery in November 2016 blamed the USPSTF for a significant decline in prostate biopsies and radical prostatectomies since 2012. The USPSTF is currently revisiting the PSA screening guideline and issued a final research plan in May 2016.

Baseline Testing Embraced

The Medscape poll showed that despite the controversy, physicians are still recommending baseline PSA testing to their male patients. When asked how often they recommend such a baseline test, almost a quarter (26%) of the poll's 680 respondents said "always," while 61% said they "often" or "sometimes" urge the baseline. Only a small percentage of doctors said they "rarely" or "never" recommended a baseline PSA.

"It is only by following the changes from a known early baseline without interference from [benign prostatic hyperplasia] etc that we can assist our patients to make informed decisions about their care, including watchful waiting, active surveillance, or definitive Mx," said Dr Jan Sheringham, a family medicine specialist, in comments on the poll. "Yes, do no harm is our watchcry, but I believe we can actually cause harm by not doing this test appropriately and according to our current knowledge," she wrote.

Internists and family practice specialists who took the poll seemed a tad less enthusiastic than urologists about PSA testing, but still embraced the diagnostic. Slightly more urologists said the benefits of testing "always" outweigh the risks — 14%, compared with 9% of internists and 11% of family medicine physicians. Forty-one percent of urologists said testing's benefits "often" outweigh risks, compared with 26% of internists and 30% of family medicine specialists.

About a third (30%) of urologists said they "always" recommend a baseline PSA, compared with 21% of internal medicine specialists and 21% of family medicine doctors. Colleagues in hematology/oncology responded similarly, with 21% saying they always urge the baseline; more than half (59%) said they only "sometimes" recommend it.

"Screening for prostate cancer with a PSA and a [digital rectal exam] is fairly innocuous, and it entails only a blood test, and a very brief exam," said James Benton, MD, an oncologist, in commenting on the poll.

Dr Benton said screening is not the issue. "It is what one does with the information that is the real issue," he said. "Medical bureaucrats should not be the arbiters of decisions to screen or not screen," said Dr Benton, adding, "A man in conjunction with his family and doctor should have an unobstructed right to know if he has a cancer and make an informed decision as to how he will proceed with various treatment options ― from active surveillance, radiation, or surgery."

General practice physician Chris Blair said it was perhaps just a matter of time before the proper balance was found with PSA testing.

"Not so long ago, an increased PSA often lead to surgical removal by enthusiastic surgeons," he wrote. "Now watchful waiting and surveillance, with other sophisticated diagnostics, is included in the discussion," said Dr Blair.

"The pendulum oscillates from one extreme to another, and hopefully we learn, and the world becomes a better place."

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