For the past 10 years, the PSA screening controversy has been driving me crazy. All along, our position at the Sperling Prostate Center has been a constructive middle ground: support annual screening, and back it up with multiparametric MRI (mpMRI) of the prostate. We’ve known all along that the blood test is imperfect because it’s not specific for prostate cancer (PCa). Therefore, don’t rush to biopsy. Instead, get more information. Follow a suspicious PSA result with a) a repeat PSA to rule out lab error and b) mpMRI to actually see if there’s something that looks like PCa. This approach overcomes the standard objection to the PSA test, that it leads to overdetection and overtreatment of insignificant cancer.

Look, there’s no excuse for subjecting men to unnecessary biopsy and aggressive treatment when imaging solves the dilemma. But what’s been happening? Routine screening has dropped off since the 2012 US Preventive Services Task Force recommendation against it—and now more men are being diagnosed with late stage PCa that could have been found much earlier when it was still localized. This is what makes me crazy.

Now, a new large-scale study reveals the impact of this tragic trend. Data analysis from the U.S. Veterans Health Administration (VHA) reveals a sobering fact: failure to conduct annual PSA blood tests results in a higher percentage of metastatic prostate cancer (mPCa) diagnoses.

Facts and finding

The new study by Bryant, et al. was published Oct. 2022 in the Journal of the American Medical Association (JAMA)’s oncology issue.^[i] Here are the facts:

• Study population included men ages 40+ from 2005-2019, from 128 VHA facilities.
• In Jan. 1, 2005, there were records for 4,678,412 men; by Dec. 31, 2019 there were 5,371,701 men.
• Cases were grouped by either those who received annual screening, and those considered long term nonscreeners (no PSA test in the previous 3 years)
• PSA screening rates decreased from 47.2% in 2005 to 37.0% in 2019.
• mPCa rates per 100,000 men rose from 5.2% in 2005 to 7.9% in 2019.

Data on over 5 million men is huge! The larger the study, the more compelling the results. After statistical analysis, here’s the key finding: “Facilities with higher PSA screening rates had lower subsequent rates of metastatic prostate cancer.” In other words, annual screening is effective at preventing death due to PCa. It picks up tumors when they are still early and treatable, leading to lower rates of late diagnosis when PCa has already begun to spread in the body. Simply put, PSA screening saves lives!

But, there’s a catch: PSA alone is not enough. More and more studies are revealing that PSA plus mpMRI is accurate and prevents unnecessary biopsies. A blood draw plus a “photo”? That’s worth a thousand tests. And, for those who express concerns over the cost of mpMRI, I assure you that the medical dollars spent on over-biopsy, over-treatment, handling urinary and sexual side effects, and more diagnoses of metastatic PCa which requires very expensive imaging, chemotherapy, immunotherapies, and theranostics with radioactive isotopes—all of these are far more burdensome in the healthcare cost equation than mpMRI to guide next steps after a suspicious PSA test.

I truly hope that this VHA study, showing the consequences of neglecting annual PSA tests, will be taken to heart. An ounce of prevention—in this case, heading off mPCa at the PSA pass—is worth a pound of trying to cure something that is incurable. Men, don’t neglect your annual PSA test, and remember to follow-up with mpMRI if needed.

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.

References

[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. Published online October 24, 2022. doi:10.1001/jamaoncol.2022.4319