There’s a time and a place for discussion before making a decision, but a doctor’s visit prior to a PSA blood draw is not the time or the place. The current recommendation is as follows:
The U.S. Preventive Services Task Force (USPSTF) recommends that men ages 55 to 69 years discuss the possible benefits and harms of prostate-specific antigen (PSA) screening with their health care provider and make an individualized decision about whether to get screened.
While I understand the benefits vs. harms quandary, this policy makes me mad. There are two big reasons. First, the day when PSA screening posed risks of overdetection and overtreatment is past. Undeniably, harm was inflicted on untold numbers of patients who were sent for biopsy when they didn’t need it, and patients who underwent whole gland surgery or radiation when it was overkill. Thankfully, neither of these events need ever occur because multiparametric MRI (mpMRI) resolves the do-I-or-don’t-I question. Nothing could be a simpler next step following an abnormally high PSA than a noninvasive scan.
- Does the patient need a biopsy? If mpMRI does not detect clinically significant prostate cancer (PCa), no biopsy is necessary. Bye-bye overdetection!
- Did mpMRI detect a lesion suspicious for clinically significant PCa? Do a real-time MRI guided targeted biopsy with a minimum of needles to reduce risk, yet highly accurate results. Bye-bye conventional 12+ needle biopsy!
- Did the biopsy reveal prostate cancer? Tailor the treatment to the location, size and aggression level of the tumor. Options include whole gland, partial gland, focal, and Active Surveillance. Bye-bye overtreatment!
The second reason is what happens when men don’t get screened. The consequence puts them in the position of being diagnosed when a local treatment is no longer possible. This leads to far greater harm than PSA screening ever did. The patient is put on chemical castration with its nasty side effects. When that eventually fails, it’s followed by chemotherapy. After that comes an immunotherapy approach that can add months or a couple of years to a patient’s life before death due to PCa. I can’t think of greater harm than this—all because the nice chat between patient and doctor ended with a decision to skip the blood test. Why are we still doing this?
The numbers tell the tale. The most recent example is an October 2022 Journal of the American Medical Association (JAMA) article that spurred me to write this blog. The data comes from 128 Veteran Administration sites, and involves upwards of 5 million men over a period of 14 years (2005-2019). During that time, the PSA recommendations from the USPSTF seesawed, leading to where we’re now at. The authors found that “…the facilities with higher rates of prostate-specific antigen screening had lower subsequent metastatic prostate cancer incidence rates.”[i] In other words, centers that ensured annual screening had fewer cases of advanced disease at diagnosis.
PSA screening should not be an individual decision. Can any man know with certainty whether fate holds PCa in store for him? No. Therefore, this annual inexpensive screening test should be universal or else more men will be diagnosed at a deadly disease stage. The current policy should be done away with. Let’s return to annual PSA screening for all men according to age-specific guidelines and other PCa risk factors.
To sum up, mpMRI has eradicated the need for a “benefits vs. harms” analysis of PSA. If a man’s PSA test result if suspicious, mpMRI imaging has no harms, just benefits. I hope that the USPSTF revisits the growing number of studies showing the tremendous but entirely needless harm that occurs when discussions take the place of blood draws.
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.
[i] Bryant AK, Lee KM, Alba PR, et al. Association of Prostate-Specific Antigen Screening Rates With Subsequent Metastatic Prostate Cancer Incidence at US Veterans Health Administration Facilities. JAMA Oncol. 2022;8(12):1747–1755.