To PSA or not to PSA: That Is the Thorny Question

Fewer men are undergoing prostate-specific antigen (PSA) evaluations since the United States Preventive Services Task Force (USPSTF) announced its controversial recommendation not to undergo the PSA test. This will lead to lower diagnosis and subsequent treatment rates forprostate cancer.

According to the results of this task force, a PSA test would never be performed, and all men would never be affected by prostate cancer. That would all be well, except that prostate cancer kills more than 29,000 men in the US every year, according to the American Cancer Society.

The task force's recommendations against screenings for prostate cancer based on PSA apply to all men, regardless of risk. The USPSTF used some studies that suggested that early intervention in prostate cancer did not have any bearing on the outcome. Yet at the time of the decision in 2012, other clinical studies suggested that early intervention could produce benefits.

New Study Shows PSA Test Benefits

A recent New England Journal of Medicine study revealed a significant reduction in mortality after radical prostatectomy with longer-term follow-up (23 years). The research reviewed outcomes of the Scandinavian Prostate Cancer Study Number 4, in which 695 patients underwent either surveillance or surgical intervention. The benefits for the group who underwent surgery was greatest in patients less than 65 years of age. However, patients over 65 who underwent surgery had a reduced spread of disease.

Another significant finding: Prostate surgery patients were less likely to require additional hormone therapy in the future. A third of the surveillance-only participants died from prostate cancer or other causes, usually after experiencing metastasis. On the other hand, only every fifth man in the surgery group had those effects.

These recent findings are substantially different than those of the Prostate Cancer Intervention Versus Observation Trial (PIVOT), which concluded that surgery did not significantly reduce prostate cancer mortality after 12 years. The PIVOT data was part of the information that the USPSTF used to form its decision.

When it's time to obtain a PSA, consider and discuss with your urologist and primary care physician the New England Journal of Medicine study and other ongoing studies. Perhaps even more importantly, men who have a prostate cancer diagnosis and who may be considering a course of surveillance should seriously contemplate these new findings.

Looking Toward Change

With the recent New England Journal of Medicine study identifying additional benefit with the use of intervention, it is time for the USPSTF revisit this subject. Although PSA testing has some drawbacks, it is the only test we have to help diagnose prostate cancer. The task force is rather set in its ways, and getting them to re-evaluate PSA testing so quickly will be a daunting task.

The USPSTF Transparency and Accountability Act of 2013 (HR 2143) is a bipartisan bill that specifically addresses the way that this task force reaches its decisions. The bill would include critical reforms that would require the USPSTF to:

  • publish research plans to guide its systematic review of evidence and new science relating to the effectiveness of preventive services;
  • make available reports on such evidence and recommendations for public comments;
  • codify the grading system so it cannot be changed without an appropriate review; and
  • establish a preventive services stakeholders board to advise it on developing, updating, publishing, and disseminating evince-based recommendations on the use of clinical preventive services.

The bill would also ensure that Medicare or other payors couldn't deny payment for a preventive service solely based on its grade from the task force.

Prostate cancer is a serious health problem. One out of every six men age 55 and older will develop it. (Our free Health Risk Assessment can determine if you are at risk.) We cannot sit still while a government agency has not considered all the data that is available. I urge readers to contact their representatives to support HR 2143, the USPSTF Transparency and Accountability Act of 2013, which could prevent decisions like this from occurring again.

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