Controversy over a Key Prostate Cancer Screening Blood Test (PSA): The Real Story
Earlier this month, the US Preventive Services Task Force recommended that healthy men should no longer receive a PSA (prostate-specific antigen) blood test to screen for prostate cancer as part of routine cancer screening. This has created an uproar in both the urologic community and the medical community at large. It is a decision made by a panel that does not include a urologist or an oncologist.
The task force is headed by Dr. Virginia Moyer, professor of pediatrics at Baylor College of Medicine, who said in a recent NY Times article, “This test cannot tell the difference between cancers that will and will not affect a man during his natural lifetime. We need to find one that does.”
It is widely known that the PSA blood test is not a perfect test. Its main shortcoming is that it cannot differentiate between “aggressive” prostate cancers, which can kill you, and “lazy” prostate cancers, which can be treated with watchful waiting or active surveillance.
The most recently updated study from Sweden “The Goteborg Randomized Population-Based Prostate Cancer Screening Trial (reference Hugosson, J., Carlsson, S., et al., Lancet Oncol 2010, Aug; 11(8)..725-32) found that with screening, deaths from prostate cancer dropped 44 percent over a 14-year period, the same period of time in which the PSA test has been widely used by urologists and oncologists for routine cancer screening. Full article, here.
Although the incidence of prostate cancer has remained stable for the last 20 years with about 230,000 cases per year being diagnosed, the death rate from prostate cancer has decreased with early screening. Those of us who are active in the field of prostate cancer in both screening and treatment attribute this directly to our ability to make an early diagnosis of prostate cancer, which is virtually impossible without PSA screening. Before PSA testing, more than 40,000 US men died annually from prostate cancer.
One would expect that this total would rise sharply because of the growing population of aging baby boomers over the same time frame. Instead, deaths have dropped to about 30,000 per year. The key is early diagnosis. Of course, it is true that we now use more advanced therapeutic modalities, including da Vinci robotic nerve-sparing radical prostatectomies, advanced radiation therapy techniques, and chemotherapy. But without the early diagnosis made possible by PSA screening, none of these advances would be applicable.
Prior to PSA testing, 80 percent of all prostate cancers had metastasized—that is, gone beyond the capsule of the prostate—at the time of diagnosis. Screening PSA has changed all that.
It is important to remember that the PSA test is only one small piece of the puzzle with regard to the early diagnosis and potential treatment of prostate cancer. Many other factors—such as pathology, stage, medical condition of the patient, comorbidities (other medical problems), sexuality, life expectancy, and lifestyle—must be taken into consideration when approaching the treatment or non-treatment of prostate cancer. PSA screening is not treatment.
The decision on whether or not to have a PSA test cannot be made by any governmental agency or task force but must be made between a patient and his doctor on a very individual basis.
We must rely at the present time on the PSA blood test, imperfect though it may be in predicting the “good” from the “bad” cancers. It is still an essential tool for early diagnosis and treatment. Should the new task force recommendation be followed, there is no doubt that the government (Medicare, for example) will save money, but it will undo 20 years of progress and will result in the needless deaths of thousands of men, particularly between the ages of 40 to 65, who could be diagnosed with early and curable prostate cancer.
Dudley S. Danoff, MD, FACS is the attending urologic surgeon and founder/president of the Cedars-Sinai Medical Center Tower Urology Group in Los Angeles, California. He is the author of Penis Power: The Ultimate Guide To Male Sexual Health (Del Monaco Press, 2011) and Superpotency (Warner Books).
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