Prostate Specific Antigen (PSA) is a blood test used to detect prostate cancer. Most physicians recommend this test be done in males age 50-80 years of age to assist in the detection, diagnosis and treatment of prostate cancer. Usually this is done in conjunction with a physical examination of the prostate.  Presently the titled recommendation is in a draft statement and therefore not formally accepted yet.  There is a time period for open discussion on this issue.  This draft statement followed the latest data on this topic which was published October of 2011.  The draft states:The U.S. Preventive Services Task Force (USPSTF) recommends against prostate-specific antigen (PSA)-based screening for prostate cancer. This is a grade D recommendation . This "grade D recommendation" means that the overall scientific evidence indicates there is no clear benefit and that the harms associated with the screening outweigh the benefits.

Already there has been significant discussion among my colleagues as well as reviews and physician commentary   in our periodical publications.  The information is difficult to sort out and quite frankly I feel the draft statement offers the easiest and most concise information for all readers.  The upshot of all the studies done to date is that a man's lifetime risk of dying from prostate cancer is small (under 3 out of 100 men). The probability of being diagnosed with prostate cancer, on the other hand is almost 16 out of 100 men! This would explain why most men at their health review visit tell me they personally know several friends who carry the diagnosis and have undergone treatment for the cancer.  To put this mortality information into some perspective, nearly 60 out of 100 adult men in the US will die of cardiovascular disease.

In the majority of men studied, survival is not really altered by early detection or intervention. In the pool of articles reviewed one study of good quality found that prostate resection (prostatectomy) for localized prostate cancer decreased the risk for prostate cancer-specific mortality compared with watchful waiting through 13 years of follow-up.  You may click the following link to see one of the original teaching videos for one way of doing this procedure. You may have to download QuickTime to view this; the option to download that software is on the site. There were six out of one hundred more alive at the end of the study period in the men that had the surgery. The benefit was limited to men under 65 years of age.  One of the studies indicated that in men between the ages of 55-69 there is a measurable relative risk of survival benefit but it is small. In the study there would be 7 less deaths for every 10 thousand men treated. It took 9 years of follow-up to demonstrate this benefit and perhaps it will look stronger after more continued follow-up. Actually just before I sent this newsletter out, the 11 year follow-up data was reported in the New England Journal of Medicine (March 15, 2012) and an Editorial by Dr. Anthony B Miller MD concluded: "there has been little change in the apparent benefit of screening men....in order to prevent one death from prostate cancer at 11 years of follow-up, 1055 men would need to be invited for screening and 37 cancers would need to be detected".

The evidence appears pretty clear that in men 75 or over, "screening" PSA's offer no survival benefit.  Additional information shows that in the US, 9 out of 10 men who are diagnosed with localized prostate cancer undergo treatment.  Adding even more to the confusion, data has shown that even in men with normal PSA's who undergo random prostate biopsies, prostate cancer will be detected in as many as one of four.  In autopsy data as many as 80% of men aged 80 and older will have biopsy proven prostate cancer (but die of other causes).

This information has led to a concept of "overdiagnosis" into the PSA screening conversation. Essentially, the concern brought out by these studies is that prostate cancer is overly diagnosed, and that getting treatment in men over 65 years does not translate to survival benefit. Because of these issues, screening recommendations need to be reviewed.

The task force draft recommendation definitely goes against current practice patterns (mine included).  We have all been following the idea that early detection of cancer will translate to easier/definitive treatment and thus improved survival. What we appear to be ignoring is that in the process of this early detection (and I have prided myself on diagnosing this condition in many "routine" physicals) we are putting men in the way of significant risks.  Risks include: bleeding, urine retention, impotence, pain, emotional stress, infection, rectal bleeding from radiation, hot flashes and weight gain from hormone blockade, and in the cases of prostate resection-- risk of preoperative death. All of the aforementioned risks are recognized and quantified in the task force statement.

Dogmatic policies on this topic will not be easy to change. Recently the task force recommendation has even been politicized by some physicians representing the Urology profession. Statements have been made that the task force is not the appropriate body to assist in such issues.  It is healthy for us to remain skeptical of going against our agreed upon policies but I must admit, this update and review does make it difficult for me to remain nonchalant about advising men to have a PSA on an annual basis. The European study that showed survival benefit in screening PSA tested every 2-7 years and used a slightly lower PSA level for recommending biopsy (3 or higher). This indicates that less frequent testing combined with a lower level for biopsy recommendation maintains the detection rate. Additionally, it appeared to improve survival (age 55-69 year group) but since lest testing is done, there would be less false positives. Less false positives would mean less procedures and potential complications. Cost of screening would also be significantly less with these guidelines. This information, in my opinion, is worth consideration.  I feel that certainly in men over 70 years of age who have prostate cancer found, a randomized trial looking at watchful waiting versus early treatment might enlighten us further. Additionally, I am hopeful that the upcoming field of genome analysis may provide further risk prediction information that could be applied in helping physicians and patients know who would benefit from treatment while allowing lower risk subjects to remain in a monitoring pattern of care.  I also suspect that depending upon the mortality curve as medicine and health advances, we may have to reconsider when we recommend against continuing PSA screening.

Physicians are human beings just as patients are. We all have anecdotal cases of early detection "cures" as well as cases of finding advanced disease "late in the game". Couple these biases with the concern of being sued/liable for failing to diagnose and the readers can imagine how difficult it will be to let all the scientific evidence "sink in".  This could possibly result in an actual change of clinical use of PSA screening. The present routine of annual blood tests for PSA is such a deeply ingrained health recommendation.  Dr Allen Bent MD and Richard Albin Ph.D. coauthored an opinion piece published in November JAMA and they summarized this issue as follows: