The PSA Screening Debate

On November 18, 2015 the New York Times carried an article titled “Early Prostate Cancer Cases Fall Along With Screening.” Ever since the U.S. Preventive Services Task Force recommended against broad PSA screening on the grounds that it leads to overdetection and overtreatment, two opposing positions have been created. One position favors the recommendation on the grounds that most prostate cancer (PCa) is slow-growing and may never need treatment, so why put men at needless risk of urinary and sexual side effects? The other position holds that failure to screen means the 15-25% of men who harbor a dangerous PCa cell line will miss a necessary treatment window, and be faced with metastatic disease and eventually premature death from the disease.

The dilemma stems from the traditional diagnostic pathway in which a nonspecific PSA blood test (many conditions can cause a rising PSA) leads to an invasive random biopsy (12-14 needles blindly guided by ultrasound imaging that does not show cancerous areas). If the biopsy is positive, it leads to a choice: either a whole-gland treatment even for cancer that might never pose a threat to the patient’s life—or Active Surveillance (AS) monitored by yet another nonspecific PSA blood test and repeat biopsies. It is so frustrating to see this debate rehashed when there is a solution to the dilemma! A new, alternate diagnostic pathway for men with an abnormal PSA allows less invasive next steps:

• for those with a suspicious PSA, have multiparametric MRI of the prostate
• for those with a suspicious MRI, undergo a minimalist image-guided targeted biopsy
• for those with unifocal (one location) cancer, consider minimally invasive focal tumor destruction by extreme heat or cold.

Having a focal treatment such as our BlueLaser® Focal Laser Ablation (FLA) spares men from the potential aftermath of whole gland treatment and thus preserves their quality of life without burning any future treatment bridges. As for those who are told they are qualified for Active Surveillance but aren’t comfortable with monitoring their cancer, focal treatment represents a balance that controls (in many cases, even cures) their cancer while liberating them from the anxiety of a time bomb ticking in their bodies. For tens of thousands of men, dilemma solved.

In an effort to create a middle ground on the screening issue, Dr. David Penson (Chair of Urologic Surgery, Vanderbilt University) suggested “screening smarter” by testing those at high risk of PCa more often and those at low risk less often. The problem is, those exposed to toxins or with a family history—only two of several known risk factors—don’t always develop aggressive PCa, while young healthy men with no known risk factors are among those who develop a silent killer type of PCa that is highly aggressive. How are screeners supposed to be able to identify such cases before their cancer has left the gland? While it’s true that there are now good FDA-approved biomarker tests, they are not meant for screening, but only to help with treatment decisions once a biopsy is positive.

Why does this screening debate continue when today’s technology allows us to offer a win-win end to the arguments? Until we have a more specific but still inexpensive blood or urine test, PSA is the best we’ve got. Let’s not throw the baby out with the bath. Beyond doubt, early detection saves lives. Let’s make multiparametric MRI the next step after an abnormal PSA, and after that, take the path of least invasiveness. This is in keeping with our oath, as doctors, to “above all do no harm.”