Do you get an annual physical or wellness check? Is a PSA blood test part of it? If it isn’t, it might be because your doctor took to heart the 2012 bulletin from the US Preventive Services Task Force panel regarding PSA screening. That year, the USPSTF downgraded PSA screening to a D (not recommended due to moderate or high certainty that it has no net benefit or harms outweigh the benefits). As a result, many doctors discontinued annual PSA screening except for men at known prostate cancer (PCa) risk.
After the 2012 downgrade, the number of newly diagnosed low-risk prostate cancer (PCa) cases began to drop. This might seem like good news, but its corresponding trend was alarming: the rate of newly diagnosed high risk PCa began to rise. Experts attributed the trend to the USPSTF panel decision, which resulted in missing an unknown number of early, symptom-free PCa cases. In other words, if you don’t go looking for prostate cancer (PCa), you don’t find it…until it’s discovered incidentally or as the result of urinary, sexual or pain symptoms. Suddenly, a lot of men were in danger of advanced PCa. Faced with the evidence, the USPSTF revisited its position and arrived at a different conclusion six years later.
The USPSTF 2018 bulletin
In 2018, the panel sent out a new Final Recommendation[i] that upgraded its 2012 D rating to a C for men ages 55-69. They now recommended informed, individual decision making based on a man’s values and specific clinical circumstances, meaning men in this age group may skip a PSA test if they choose, after discussion with their doctor. A rating of C indicates moderate certainty of a small benefit of reducing death with screening of men in this age group. But, for those 70 and older the USPSTF maintained the D rating: Not routinely recommended.
The American Urology Association immediately issued its own statement applauding the C rating. They noted that the USPSTF was in “direct alignment with the AUA’s clinical practice guideline and guidelines from most other major physician groups – including the American Cancer Society, the American College of Physicians, the American Society of Clinical Oncology and the National Comprehensive Cancer Network – all of which advocate for shared decision making.” However, they differed from the position on men 70+ years of age, stating that while many older men might be harmed as a result of PSA screening, those who were in good health might gain benefit.
What newer numbers say
The American Cancer Society (ACS) put out its annual Cancer Facts & Figures in January, 2020. Among other things, it celebrated the fact that cancer death rates had fallen 29% from 1991 to 2017 (the most recent year for available totals). In fact, the year from 2016-2017 saw the steepest single-year drop on record, thanks to the work of many previous years to advance prevention, early detection, and treatment breakthroughs.
With specific regard to PCa, death rates had steadily declined 52% from 1993 through 2017. But, warned the ACS, that’s about to end. “The group estimates about 192,000 cases of prostate cancer will be newly diagnosed in 2020, up from 174,000 in 2019. Likewise, prostate cancer deaths are expected to rise this year to 33,300, the biggest death toll in two decades.”[ii] What’s the explanation for this?
Some authorities say it’s due to the Baby Boomers reaching elderly ages when cancer is more likely to develop. I believe it’s also the product of the statistical surge of diagnosed later-stage PCa that began after the 2012 USPSTF downgrade of PSA screening. A larger-than-average death rate is to be expected as higher recurrence and metastatic PCa rates take their inevitable toll. Although new immunotherapies and PCa vaccines are proven to extend life, they are not curative. The countless men who were advised against screening by their doctors—or who simply elected to avoid it—are paying a sad price for missing the treatment window they would have had with early detection, which does save lives.
Our position at the Sperling Prostate Center is based in published research. Is the PSA blood test flawed? Indeed, it is. Has it historically led to overdiagnosis of insignificant PCa? Have untold thousands of men been overtreated and left with impaired urinary or sexual function? Sadly, yes. But there’s a simple, elegant, demonstrated solution: keep PSA screening (until something more specific comes along) and, if suspicious, add multiparametric MRI (mpMRI) before biopsy! This eliminates unnecessary TRUS prostate biopsy with its attendant risks and at least 30% error margin.
With regard to annual PSA testing, we support informed shared decision making between patient and doctor, adding that “informed” means including the facts about mpMRI as the best and only way to clarify what’s causing a PSA bump-up. Patients must be reassured that there is everything to gain and no reason to fear needless harm. Don’t take the chance of becoming a high-risk PCa statistic.
Get your annual PSA test, because mpMRI’s got your back.
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you have health concerns or questions of a personal medical nature.
[i] USPSTF Bulletin, May 8, 2018. JAMA. 2018;319(18):1901-1913. doi:10.1001/jama.2018.3710
[ii] Wolinsky, Howard. “Prostate Cancer Mortality: Groups Squabble Over ACS Forecast.” MedPage Today, Feb. 5, 2020.