We just can’t escape the constant chatter regarding the two extremes: screen everyone vs. screen no one. We were recently discussing a blog which likened the dangers of PSA screening to the harm caused by performing prostate biopsies on prisoners in the early 60’s without their consent. These men had terrible consequences: rectal injury, incontinence, impotence etc. as the anatomy of the prostate and its surrounding structures was not well known until the late 80’s. This comparison is extreme and clearly the situation regarding lack of informed consent is completely inappropriate and a whole different problem. As urologists, we first discuss PSA’s potential benefits as well as limitations. While it is true that PSA is not the be all and end all, it most definitely plays an important role in diagnosis and follow-up, as does the DRE (digital rectal exam). While this exam is unlikely to be the highlight of your day it is helpful and we do notice subtle changes over the years as we come to “know you and your prostate”. There are many factors that we take into consideration before recommending biopsy to patients. These include the absolute PSA value when making comparisons across age groups and race; rate of rise (velocity); doubling time; density of PSA when taking into account the size of the gland; free % of PSA; genetic markers; family history and changes in the exam. While true that a high value on one occasion should not automatically prompt a biopsy, if repeatedly elevated more information may often be better. When a cancer is diagnosed, we consider the patient’s co-morbidities and life expectancy before making recommendations regarding: to treat or not to treat and if treatment is recommended, how to treat.
We believe that physicians and patients alike should have all of the information that is safely (and biopsy is still relatively safe when given appropriate antibiotics) and readily available to them in order to make educated decisions. Patients are empowered by more information and it often guides their medical decisions. While we understand that not every high PSA reading requires immediate biopsy and not all biopsy proven cancers require intervention, we do believe that a patient and their doctor have a “right to know” if they are harboring a cancer. Clearly, the hope is that more specific markers will become readily available to determine those patients whose prostate cancer is destined to have a negative effect and therefore those to whom treatment is recommended. There are already complex genetic tests available though not frequently used at present.
Many like to say that “only 3 out of 100 men diagnosed with prostate cancer will die from their disease”, but they fail to mention the potential symptoms. Urinary complaints with possible gross blood in the urine as the disease progresses, bone fractures or SRE’s (skeletal related events), or metastases can precipitate a miserable existence. We have all seen extreme cases where a man may awaken unable to walk due to lower extremity muscle weakness due to spinal cord compression. This often requires emergent surgery. In the “DONT SCREEN PSA” side, many also ignore the fact that there was not one urologist, medical oncologist or radiation oncologist on the US Preventive Services Task Force Panel that came up with the recommendation D status against PSA testing in anyone. How did psychiatrists, pediatricians and nurses end up on the panel? These are independently assigned panels, but they are not comprised of physicians who treat the specific disease processes on which they’re expected to comment. Many are also unaware of proper interpretation of the data. Task forces have been known to be wrong, and if not wrong, sometimes change their opinion based on data outcomes. This is apparent in the recent change of the USPSTFP panel which recommends a yearly low dose CT scan of the chest in smokers who are 55-79 yo and who are high risk. This was defined as having “a 30 pack year smoking history”, meaning they smoked a pack per day for 30 years, or 2 packs per day for 15 years,etc. The National Lung Cancer Society and American Cancer Society generally support this and recommend that “a thorough discussion be held regarding the pros and cons of and serious consideration be given” to annual CT Chest scanning. All involved in these recommendations readily acknowledge the risks of radiation and detection of many false positive lesions. These findings may even lead to further imaging and/or procedures that have their own associated risks. Despite this, CT scans should still be considered as it has become clear over the last eight years that this policy saves lives.
It is also very clear when comparing populations in the pre and post PSA era that screening has saved lives, even when done every second or even fourth year, as shown in numerous studies. This is apparent if one reads and is able to correctly interpret the data of multiple large trials from the USA and Europe which have recently matured and provide compelling evidence. Unfortunately, one of the three largest randomized controlled trials (Goteborg trial) that looked at prostate cancer specific mortality, was excluded from the USPSTF’s consideration. Not only do we know that the risk of mortality is decreased, but one must not ignore the even greater benefit earlier detection has had on decreasing the risk of metastatic disease. Metastatic disease at diagnosis has decreased by 75% in the USA since PSA was introduced. We should not take this for granted.
There is no doubt that PSA testing should be used judiciously and that it is our responsibility as physicians to be aware of the data, understand it and present it to our patients in a clear and concise manner. A list of the pros and cons of any test and/or intervention should be provided. While we definitely need better tests for diagnosis and for assessing the degree of risk the disease may pose to the individual patient, the constant push to eliminate PSA is absurd. There is admittedly “over-diagnosis, under-utilization of active surveillance, and over-treatment”, but this does not eliminate the value of screening.