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Return to To Screen or Not to Screen: The Debate Over PSA Overview

More on To Screen or Not to Screen: The Debate Over PSA

To Screen or Not to Screen: The Debate Over PSA

NEW YORK (Jul 5, 2012)

There is no doubt that testing for PSA (prostate-specific antigen, a marker of prostate cancer growth) has helped increase the number of prostate cancers that are detected in their early, most curable stages. But how many lives does it actually save? And who needs to be treated? That has been a subject of debate.

U.S. Preventive Services Task Force

This past May, the U.S. Preventive Services Task Force (USPSTF) recommended against the use of PSA testing to screen for prostate cancer, stating that the science shows that "more men will be harmed by PSA screening than will benefit." The main goal of cancer screening is to reduce the number of deaths from the disease, the USPSTF noted, but studies show that very few men would experience this benefit from PSA screening. The USPSTF is an independent group of national experts in prevention and evidence-based medicine that makes recommendations about clinical preventive services such as screenings.

Two Major Studies Cited

The USPSTF cited two major studies, both published in 2009 and updated in 2012, which failed to find a significant benefit from PSA testing. The U.S.-based Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial failed to show a benefit from screening in reducing the number of prostate cancer deaths. The European Randomized Study of Screening for Prostate Cancer found that at most, just one man in 1,000 who have PSA testing is spared from prostate cancer death.

The Task Force also noted that for every 1,000 men screened with PSA who undergo prostate cancer treatment, 30 to 40 develop erectile dysfunction or urinary incontinence, two experience a serious heart problem, and one develops a serious blood clot in the legs or lungs due to treatment. One man will die due to complications of surgical treatment for prostate cancer. While these numbers are low, they are higher than the benefits of PSA testing, leading the USPSTF to make its recommendation.

Our Physicians Offer Their Opinions

Leaning Away: Edward P. Gelmann, M.D.

Edward P. Gelmann, M.D., is the Chief of the Division of Hematology/Oncology and the Deputy Director of the Herbert Irving Comprehensive Cancer Center at NewYork-Presbyterian/Columbia University Medical Center.

Edward P. Gelmann, M.D.
Edward P. Gelmann,
M.D.

"There is conclusive evidence that one negative PSA test is sufficient for a number of years, that PSA screening does not produce any survival benefit, and that it may cause more harm than good," said Edward P. Gelmann, M.D. "Except in the case of individuals at high risk – such as African American men and those with a family history of prostate cancer – routine PSA screening should not be recommended."

But some doctors and professional organizations feel the USPSTF recommendation is too severe, and that the decision regarding PSA testing should be made between a patient and his physician. The American Cancer Society guidelines state that asymptomatic men age 50 and over with at least a 10-year life expectancy should have an opportunity to make an informed decision with their healthcare providers about screening for prostate cancer "after receiving information about the uncertainties, risks, and potential benefits associated with screening. Prostate cancer screening should not occur without an informed decision-making process." Similarly, the American Urological Association has written "that the Task Force is doing men a great disservice by disparaging what is now the only widely available test for prostate cancer, a potentially devastating disease."

Leaning Toward: Ashutosh K. Tewari, M.D.

Ashutosh K. Tewari, M.D., is the Director of the Center for Prostate Cancer Research and Clinical Care and the Director of the Lefrak Center for Robotic Surgery at NewYork-Presbyterian/Weill Cornell Medical Center.

Ashutosh K. Tewari, M.D.
Ashutosh K. Tewari,
M.D.

"Finding cancer early makes a difference. We've seen in countries where PSA testing is not available that more prostate cancers are found in their later stages, when they have spread to the bone or lymph nodes," said Ashutosh K. Tewari, M.D. "But PSA is not a perfect test and should not be used in isolation. Its results need to be considered in combination with other factors, such as a patient's family history and the findings of other tests, when making a decision about a patient's risk."

Some Things All Agree On

PSA Tests Can Be Inaccurate

Indeed, what healthcare professionals are in agreement about is that PSA testing is not without its flaws. For one thing, PSA can rise in response to noncancerous conditions, such as infection or the enlargement of the prostate that develops in many older men. The harms of PSA testing relate to potential complications from prostate biopsies as well as side effects of treatment. Men whose PSA levels are high (generally over 4.0 ng/dL) may be subjected to worry and anxiety as they wait for the results of a prostate biopsy. A minority of men who get a prostate biopsy develop fever, infection, bleeding, urinary problems, and pain, which in rare cases requires hospitalization.

Cannot Guide Treatment

Doctors also agree that the problem is not the PSA test itself, but rather the inability to distinguish prostate cancers that require treatment from those that do not. The American Urological Association has stated, "Not all prostate cancers are life-threatening. The decision to proceed to active treatment or use surveillance for a patient's prostate cancer is one that men should discuss in detail with their urologists." Many of the small cancers that are found are unlikely to cause harm if left untreated. And most elderly men with prostate cancer are more likely to die with the disease than of it, succumbing to other causes such as heart disease first.

Ongoing Advances

Researchers, including those at NewYork-Presbyterian Hospital, are seeking to determine who needs treatment and who can be spared from therapy through "active surveillance," also known as "watchful waiting." Men who are treated may receive surgery, radiation therapy, hormonal therapy, and/or chemotherapy, depending on the stage of the cancer. Dr. Tewari and his colleagues are evaluating the combination of tests such as multiparametric magnetic resonance imaging, genomics, and the findings of other tests (such as a urine test for a protein called PCA3) to distinguish aggressive prostate cancers that require treatment from slower-growing varieties that can be monitored.

"We don't need to be better at finding prostate cancer. If anything, we are too good at it," concluded Dr. Gelmann. "What we need is a test to tell us which prostate cancers should be treated and which can be left alone. At this point, that would be the Holy Grail."

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