PSA Screening for Prostate Cancer: Debate Continues

Zosia Chustecka

December 29, 2011

December 29, 2011 — The debate about PSA screening for prostate cancer, which has reached a crescendo in recent months after the US Preventive Services Task Force (USPSTF) recommended against it, continues now in a series of opinion articles published in the December 28 issue of JAMA.

Most of the commentators take issue with recommendation.

Although the USPSTF "deserves credit for sharpening the focus on the risks and harms of prostate screening," the committee did not get it quite right, suggests an opinion piece from Robert Volk, PhD, from the Department of General Internal Medicine at the University of Texas M.D. Anderson Cancer Center in Houston, and Anthony Woolf, MD, from the Department of Medicine at the University of Virginia School of Medicine in Charlottesville.

This was a grade D recommendation, which indicates that physicians have no obligation to mention the issue of prostate cancer screening because testing of asymptomatic men should not occur, the commentators point out. It would be better to have a grade C recommendation, which also recommends against routine screening but would allow for individualized decision making, they note. This would permit physicians to apprise men of the potential benefits and harms of screening, and then the patient and physicians could decide in partnership whether or not to proceed.

A grade C recommendation would have put the USPSTF in line with virtually all other medical organizations, including the American Cancer Society and the American Urological Association, in recommending against routine screening but promoting actively engaging men in the decision, Dr. Volk and Dr. Woolf comment.

Cannot Go Uncontested

The USPSTF recommendations "miss the mark," according to another set of authors, David Miller, MD, MPH, and Brent Hollenbeck, MD, both from the Department of Urology at the University of Michigan, Ann Arbor.

They point out that during the last 2 decades, and concurrent with the dissemination of PSA screening, there has been a significant decline in prostate cancer–specific mortality in the United States ( Lancet Oncol. 2008;9:445-452).

"This well-established epidemiological trend is difficult, if not impossible, to explain without accepting that early detection strategies built around PSA screening have allowed the identification and successful treatment of patients who would have otherwise died of biologically aggressive, clinically significant prostate cancers," they write.

"[T]his advance apparently was barely recognized in the deliberations and communications from the task force," they comment.

However well-intentioned, the USPSTF recommendation against PSA screening cannot go uncontested, say Dr. Miller and Dr. Hollenbeck. Although emphasizing the need to avoid harm associated with detection and treatment, which is without question a laudable goal, the task force is essentially "relegating some men to an avoidable death from prostate cancer, including the morbidity associated with metastatic disease."

"Clinicians must preserve the ability to detect aggressive prostate cancer while these tumors are still at an early stage," they write. "At the present time, PSA screening is the best tool available to achieve this objective, even if it means some men may experience morbidity and mortality associated with diagnosis and treatment."

Change in Management

Eliminating PSA-based screening is premature, write Jeri Kim, MD, from the Department of Genitourinary Medical Oncology, and John Davis, MD, from the Department of Urology, University of Texas M.D. Anderson Cancer Center, in a third commentary.

"Until each man's risk for prostate cancer can be individually assessed (as it will be in the future), a new model is needed for managing the disease in PSA-screened men, " they write.

They suggest changes at the low-grade-disease end of the spectrum, as this is where the problem of overdiagnosis and overtreatment occurs. Low-risk patients could be managed with active surveillance, and some could be treated with 5-alpha reductase inhibitors finasteride and duasteride.

At present, in the United States, about 90% of men with localized disease (including about 75% with lower-risk cancers) undergo surgery or radiation therapy, according to another commentary by Robert Chou, MD, from Oregon Health & Sciences University, Portland, and Michael LeFevre, MD, from the University of Missouri School of Medicine in Columbia. They note that those estimates are based on actual US data ( J Clin Oncol. 2010;28:1117-1123), and whether these rates can be substantially reduced in practice has "yet to be determined."

The controversies behind prostate cancer screening may never be fully resolved, they comment, but they, and many of the other authors, emphasize that "[n]o man should be screened without his explicit consent."

The Right Call

One of the opinion pieces supports the USPSTF recommendation against PSA screening and comes, unsurprisingly enough, considering his well-known stance on cancer screening, from H. Gilbert Welch, MD, MPH, from the Dartmouth Institute for Health Policy & Clinical Practice, Hanover, New Hampshire. (Dr. Welch is author of Should I Be Tested for Cancer? Maybe Not and Here's Why, and a coauthor of Overdiagnosed: Making People Sick in the Pursuit of Health).

"If I was pressed to get off the fence, it's the call I would have made," he writes.

"The United States now needs the medical profession to make more calls like this," he writes. "[T]he nation also needs the profession to communicate the nuances of medicine. Most tests and treatment are neither unambiguously good nor unambiguously bad. Instead, their effect is modified by how they are used."

Dr. Wolf served as a chair to the American Cancer Society Prostate Cancer Advisory Committee when it developed its 2010 prostate screening guideline, and Dr. Volk served as a consultant to that committee. Dr. Miller is a member of the National Comprehensive Cancer Network Prostate Cancer Treatment Guidelines Committee. Dr. Kim reports receiving research support from Merck. Dr. Davis has acted as a consultant to Baxter and has grants pending with Genprobe and Jansen. Dr. Chou was lead author on the evidence review commissioned by the USPSTF on prostate cancer screening. Dr. LeFevre is the co–vice chair of the USPSTF.

JAMA. 2011;306:2715-2722, 2649-2650. Volk and Wolf extract, Kim and Davis extract, Miller and Hollenbeck extract, Chou and LeFevre extract, Welch extract


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