Prostate cancer screening has been in the news again lately, and it continues to merit the label of “the controversy that refuses to die.” Let’s review some of the reasons for the recent resurgence in attention around the prostate specific antigen (PSA) test.
Epidemiologic analyses show that rates of PSA testing are decreasing, particularly in primary care, where most prostate cancer screening is done. As would be expected, less screening leads to fewer diagnoses of prostate cancer—in isolation a good thing. But advocates of screening worry that less screening and fewer diagnoses will eventually lead to more cases of men developing metastatic disease and higher prostate cancer mortality. This would reverse a trend toward fewer prostate cancer deaths that roughly corresponds to the era of intensive PSA testing. No such increases in population-based rates of prostate cancer metastases or mortality in recent years have been seen as yet. The decline in prostate cancer screening started even before the 2011 U.S. Preventive Services Task Force (USPSTF) “D” recommendation against screening.
Based on the USPSTF recommendation against the PSA test for men of any age, a Medicare quality criterion was proposed that would count PSA testing outside of narrow clinical indications as a marker of poor care quality. After great outcry, this measure was not adopted. Nevertheless, this proposal drew attention to PSA testing as potentially “proven ineffective care.” Most quality measures focus on the delivery of proven effective care. However, with increasing interest in controlling health care costs, quality measures focused on the non-delivery of proven ineffective care are coming!
The recognition is growing, even among PSA enthusiasts, that while PSA testing probably has some positive effect on prostate cancer mortality in the long term, the harms of screening as it has been traditionally conducted in the U.S. outweigh those benefits. Traditional screening and treatment practices include frequent testing every year, including among older men who are unlikely to benefit; low PSA thresholds for recommending a prostate biopsy; and aggressive treatment with surgery or radiation, even for men with low-risk cancers. Those practices also make PSA testing costly and make it an example of low-value care. A recent economic analysis suggests that more focused screening combined with more conservative treatment, including avoiding active treatment for men with low-risk cancers, could yield similar benefits with fewer side effects and lower costs.
Finally, a large clinical trial being completed in the U.K., called ProtecT, should report results soon. This large study is addressing both the outcomes of prostate cancer screening as well as the comparative effectiveness of treatment with surgery, radiation, or active surveillance. Given a negative trial of PSA testing in the U.S. and a positive trial in Europe, this third trial may be the critical “tiebreaker”!
All these new developments have experts wrestling with whether the PSA test should be recommended for at least some men, particular those ages 55–69—the age group that showed a small benefit in the European clinical trial. Most clinical practice guidelines, except for the USPSTF, still recommend a shared decision making approach to the PSA test decision. Some experts think the decision is just too complex for men to make an informed decision. If the experts can’t agree, how can laymen be expected to decide? I would turn the question around—how can we not inform men about the controversies and invite them to have a say? After all, they are the ones who will have to live with the consequences of the decision.