A panel of experts in preventive medicine released a draft proposal Tuesday on screening for prostate cancer. “Another one?” you may ask, remembering an earlier recommendation. Don’t worry; we’re here to help you avoid whiplash:
What’s new?
What was emphatic before is wishy-washy now. The last time the US Preventive Services Task Force weighed in on prostate cancer screening via blood tests, in 2012, it issued unambiguous advice to physicians: discourage men of all ages from getting tested for levels of prostate-specific antigen (PSA). That’s still the advice for men older than 70 or younger than 55.
But for those aged 55 to 69, the task force, a panel of independent experts who advise the federal government, is punting: It recommends “informed, individualized decision making based on a man’s values and preferences.”
Translation: learn as much as you can, talk to your physician, then decide for yourself.
Great. How do I do that?
The task force created a useful graphic to help you. We hope you like numbers:
If 1,000 men get PSA screening (cost: roughly $40), 240 will be told their PSA level suggests cancer might be present. Next step: a biopsy, in which a needle, usually inserted through the rectum, samples several spots in the prostate gland.
Of those 240 biopsies, 140 men will be told, oops, the PSA was misleading: You have no signs of cancer. These are called false positives.
Of the other 100 men, in whom biopsy shows definite cancer, up to 50 have malignant cells that will turn out to be so slow-growing — “indolent” — that the cancer would never spread or harm them. These are called overdiagnoses.
Unfortunately, it’s impossible to tell from looking at cancer cells if they’re wimps or killers, so 80 of the 100 men with prostate cancer choose surgery or radiation treatment, either right away or after first trying “active surveillance” (frequent PSA tests, exams, biopsies). At least 60 men suffer urinary incontinence and sexual impotence from the treatment.
Of the 80 treated men, only three benefit. In the other 77, the cancer either wouldn’t have caused harm if left untreated or is so aggressive that treatment doesn’t help.
Of the three men who benefited at all, 1.3 who would have been killed by prostate cancer without PSA screening will not be, over a period of 10 to 15 years.
Bottom line: 1,000 men screened, one prostate-cancer death averted in that time.
So if I opt for PSA screening I’m gambling that I’ll be the 1 in 1,000?
Yes.
Why did the task force back off its 2012 thumbs-down on PSA screening?
By 2012, studies comparing men who undergo PSA testing to men who do not had found that the harms of testing (false positives, overdiagnosis, impotence, incontinence) outweigh the benefits. Specifically, the data available then indicated that just 0.8 of 1,000 men who undergo PSA screening would be spared a prostate-cancer death over the following 10 to 15 years, said Dr. Alex Krist, a task force member and associate professor of family medicine at Virginia Commonwealth University.
By continuing to follow men in the studies, researchers now find that 1.3 prostate cancer deaths are prevented per 1,000 men screened. Just as important, more men are opting for active surveillance instead of treatment. That means the potential harms — impotence, incontinence — of screening are less than the last time the task force calculated all this, “making the balance of potential benefits and harms a little more positive,” Krist said.
Dr. James Eastham, a prostate cancer surgeon at Memorial Sloan Kettering Cancer Center, welcomed that. “This is a reasonable step back from the previous ‘we don’t recommend routine PSA screening,'” he said. “But it’s true that everyone shouldn’t be tested, and that many men with an elevated PSA don’t have cancer at all or, if they do, that cancer doesn’t pose a risk to his life.”
What do other groups think?
The American Cancer Society is also in the “talk to your doctor” camp.
Because “research has not yet proven that the potential benefits of testing outweigh the harms of testing and treatment,” it says, men should discuss the pros and cons of PSA screening starting at age 50 (but 45 if you’re African-American or have a father or brother who had prostate cancer before age 65).
Even the American Urological Association, which practically accused the task force of killing men with its “not recommended” conclusion of 2012, says routine PSA screening is not advised for men younger than 54 or older than 70. For those 55 to 69, it recommends “shared decision making” — talk to your doctor, understand the risks and benefits and the odds that you’ll be better off — and biannual rather than yearly screening for men who opt in.
Every time there’s a medical controversy, experts seem to duck, telling me to ask my doctor — who has about 13 minutes for me.
“Incorporating shared decision making [into a doctor’s visit] is difficult,” Krist acknowledged. “Physicians are busy, and this is a complicated topic.” He suggests that men learn what they can before a visit — and even print out a cost-benefit analysis. Then they ought to make an appointment to discuss PSA and nothing else, and take their time deciding.
How can I tell the task force what I think?
Until May 8, you can submit comments online. Eventually, the task force will finalize the recommendation.
About the Author Reprints
So the correlation of psa tests/biopsis with discovery and beneficial treatment is .8 out of 1000? Winning the lottery doesn’t look so far fetch anymore. I’ve had 3 biopsies returned negatively. How many should I endure. Poor 140 guys who suffer with bad results of poor process.
Here’s the graphic that the US Preventive Services Task Force created for its draft report on PSA screening for men 55-69. For 1,000 men who have their PSA level checked, 1-2 will “Avoid Death from Prostate Cancer.” But as Dr. Vinay Prasad writes in a First Opinion column, PSA screening doesn’t reduce the risk of dying overall.
Pat Skerrett
STAT
this write misses several critical points.
Just take the start…a ‘high’ PSA with a biopsy that’s negative. As the article states, that could be due to a false positive, i.e. PSA that was incorrect. It could also be a false negative…a biopsy that missed the tumor(s).
I have wrestled with this dilemma as have many men. It is complicated because under present state-of-the-art treatment it’s a dangerous crap shoot. With a major danger flowing from a reaction to imperfect diagnosis…one takes actions that harm them that they don’t need to have taken. Or they don’t act when they should have and let a high Gleason score cancer metastasize with death as a result
You should consider adding a discussion of PSA and treatments with restricted spectrum imaging.
A PSA test is done, if high the next step is the restricted spectrum imaging.
If their technology is as stated, that yields a diagnosis good enough to determine the Gleason score and provide a precise location for the tumor(s).
If the Gleason is critical, say over 8, surgery is done with the precise location of tumor(s) known.
If not, watchful waiting.
If this technology lives up to its promise it changes PSA testing because it eliminates biopsies and false positives.
Removing/discouraging testing seems to me to come out of the box wrong. And usually only has a claim on justification if it prevents harmful incorrect responses even if it also will lead to less/no testing and unnecessary deaths. If the harm from false starts can be eliminated…test on!
If a PSA test is high, the next step should ALWAYS be repeating the test to confirm the result. Especially in older men, the prostate is sensitive to minor insults that cause mild inflammation and a temporary non-cancer-related bump in PSA. Before sentencing anyone to the stress of waiting for specialized imaging or the possible complications of a biopsy, a quick confirmatory test (which will often be refutative) is warranted.