It’s been 5 years since the U.S. Preventive Services Task Force (USPSTF) demoted the PSA test to grade D, and recommended against broad screening for men of any age. Now they have backpedaled. They currently support individual physician-patient discussions about PSA for men ages 55-69. Why? Because the fears of doctors are coming true. Men whose early stage prostate cancer (PCa) might have been found when it was still easy to treat are being diagnosed at a more dangerous stage.
Throwing the baby out with the bath
When the USPSTF issued its May, 2012 position, it was essentially an objection to the aftermath of using a nonspecific blood test followed by a random TRUS biopsy . Insignificant PCa was over-detected (and over-treated) while significant prostate cancer was often missed, putting men at risk of disease progression. While the objection had great validity, urologists worried that ditching screening would prove to be throwing the baby out with the bath.
The debate began
An outcry arose among physicians. The American Urological Association (AUA) and the American Cancer Society (ACS) both supported informed doctor-patient decision-making so each patient could weigh the merits of being tested. Patient advocacy groups also raised loud protests against the USPSTF recommendation, pointing out that early detection saves lives. The same period also saw a dramatic increase in sophisticated multiparametric MRI prostate scans and real-time MRI-guided targeted biopsies with a much higher accuracy rate (and less invasiveness) as an alternative to TRUS biopsy. In other words, objection overruled.
Statistics reveal the sad reality
By 2015 a tragic consequence of curtailed screening was being seen in local urology practices. Men whose diagnosis of PCa had been delayed because they weren’t screened regularly were now being found with more aggressive, bulky PCa. This is harder to cure because cancer cells may already have left the gland at treatment. This remained a sort of dirty little secret until a handful of researchers began collecting and analyzing the data. In fact, the latest population statistics are especially alarming because they concern disease that has spread to other sites in the body, or metastatic PCa. Prior to the 2012 recommendation, the incidence of metastatic PCa at diagnosis had gradually risen from just over 8% in 2007 to 14% by 2011 (this rise is attributed to a less severe USPSTF recommendation in 2008). Then, after the revised 2012 anti-screening recommendation, the rate “sky-rocketed to over 22% in 2014.”[i]
The latest recommendation
In April, 2017, the USPSTF promoted PSA screening to grade C, with the recommendation that individual patients now be helped by their doctors to understand the risks and benefits of PSA testing for themselves. Task Force panel member Alex H. Krist, MD acknowledged that new data had played a role in this revision. Among the statistical revelations between 2012 and 2017 they found that screening would prevent at least a small number of metastatic PCa cases and deaths from PCa.[ii]
Thankfully, the pendulum is swinging back toward a pro-screening position. The Sperling Prostate Center applauds this trend, but also recommends that any suspicious PSA a) be retested in 3 months and b) if it remains suspicious, have a baseline 3T multiparametric MRI (mpMRI) of the prostate before making a biopsy decision! If nothing abnormal is found by imaging, a biopsy is not yet needed. Additional follow-up can be done by PSA testing every 6 months and an annual mpMRI. This approach overcomes the inherent flaws in PSA screening, and avoids tossing out the baby with the bath.
[i] Paper presented by Jared P. Schober (Lahey Hospital & Medical Center) at the 2017 AUA meeting. https://www.urotoday.com/conference-highlights/aua-2017/aua-2017-prostate-cancer/95642-aua-2017-uspstf-fallout-is-disease-burden-at-diagnosis-of-metastatic-disease-rising.html