October 7, 2011
Task Force Says PSA Screenings For Some Men Not Needed
The US Preventive Services Task Force (USPSTF), the same group that told women in their 40s that they didn´t need mammograms, is now recommending that middle-aged men skip routine screening for prostate cancer, saying the PSA blood tests that check for the disease do more harm than good.
The government panel recommends that healthy men should no longer receive the PSA tests as part of routine cancer screening. Its recommendations, made public today, will be officially issued next Tuesday, according to the Santa Monica-based Prostate Cancer Foundation.
Too much PSA (prostate-specific antigen) in the blood only sometimes signals prostate cancer is stirring. It can also mean a benign enlarged prostate or an infection. Worse, screening often detects small tumors that will prove too slow-growing to be deadly.
No major medical group recommends routine PSAs, and the USPSTF guidelines had long advised men over 75 to forgo them. The new recommendations will extend that advice to all healthy men.
Yet, the vast majority of men over 50 have had at least one PSA blood test, with the assumption that finding cancer early is always a good thing.
The task force will recommend a “D” rating for PSA testing, meaning “there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits,” according to the USPSTF website. The task force will allow a public comment period after Tuesday before it issues a final recommendation.
The report shows that screening with a PSA blood test results in “small or no reduction” in prostate cancer deaths, and adds that the PSA testing is “associated with harms related to subsequent evaluation and treatments.”
The new recommendations could be controversial. Although a series of clinical studies has raised questions about the benefits of PSA testing, many doctors maintain that is a valuable diagnosis test for prostate cancer.
“That would be a very big surprise for the urology community,” Dr. Milton Krisiloff, a urologist at St. John's Health Center in Santa Monica, told Shari Roan and Eryn Brown of the Los Angeles Times. “Prostate cancer kills a lot of people. It's not an innocuous disease. If they say just eliminate PSA, then a lot of people are going to die.”
Many doctors and patients had similar complaints in 2009, when the USPSTF made recommendations that women in their 40s do not need breast cancer screening. The task force said that routine testing for women of average risk should begin at age 50 instead of 40 and that mammograms be done once every two years. Those recommendations have been ignored for the most part.
The problem with the PSA test, critics argue, is that it flags too many patients for follow-up procedures that can be expensive and risky. Among men with results in the range of 4 to 10 nanograms per milliliter of PSA in their blood, biopsies show that 70 percent will have false-positive results and 30 percent will have prostate cancer. In addition, the disease is frequently slow-growing and causes no harm if left unchecked.
About 20 million American men have a PSA test each year. The National Cancer Institute says that 240,000 men are diagnosed with prostate cancer in the US each year, and 33,720 die.
The American Cancer Society recommends that men of average risk talk with their doctors about screening beginning at about age 50 and that higher-risk men discuss screening at age 45. The American Urological Association currently recommends that men over 40 talk with a physician about PSA screening.
Dr. Kenneth Lin, senior author of the report, said for every 100 men tested over the age of 50, about 17 of them will have prostate cancer, and only three of those will have a fast-growing cancer and die of the disease. If the 14 men with the slow-growing cancers are treated, they could be rendered impotent or incontinent, or worse. About one in 500 men who has a radical prostatectomy will die from complications of the surgery, he noted.
Dan Zenka, a spokesman for the Prostate Cancer Foundation called the proposed recommendation “a tremendous mistake.”
“You´re talking to someone whose life was saved by [the PSA test],” he told CNN.
But Lin said testing does more harm than good. “Maybe you should get tested if you have this horrible family history where everyone gets prostate cancer before the age of 50. But for most men, testing is harmful.”
The task force gave PSA testing the “D” rating back in 2009, but didn´t announce it because of the uproar over the mammogram recommendation. Until last year, Lin worked with the USPSTF as a medical officer for the Agency for Healthcare Research and Quality.
“I was so frustrated with the political interference, and this was the final straw,” Lin, who now works as an assistant professor of family medicine at Georgetown University Medical Center, told CNN.
It isn´t clear whether the task force´s report will include a blanket recommendation against the PSA test or whether it will be more toned, said Zenka. “We´re looking forward to seeing the complete report on Tuesday so we can review it in depth ... Right now it would be premature to speculate,” according to the Times
However, “there is still a great deal of confusion around it because PSA is not a cancer test. It is one step in the diagnostic process. Men need to talk to a physician who understands what the PSA test is and isn't. There is no one-size-fits-all,” he added.
Dr. Otis Brawley, chief medical officer of the American Cancer Society, told AP: “It is important to keep in mind that under the new USPSTF process, the recommendation is not final until the conclusion of the public comment period and the USPSTF's review of those comments.”
“We have been long concerned, and it has been apparent for some years, that some supporters of prostate cancer screening have overstated, exaggerated and in some cases misled men about the evidence supporting its effectiveness,” said Brawley. “We need balanced, truthful information to be made widely available to physicians and patients when making important health decisions.”
Moyer said the recommendation only means that doctors shouldn´t bring up the option for healthy men. If a man asks for a PSA test and wants it after being informed of the evidence, he should receive it, she said. Likewise, it's appropriate to use PSA tests to examine a man with possible prostate symptoms.
Health insurance companies and Medicare administrators usually follow the task force's recommendations in deciding which medical tests to cover.
On the Net:
- US Preventive Services Task Force (USPSTF)
- Prostate Cancer Foundation
- Baylor College of Medicine
- National Cancer Institute
- American Cancer Society
- American Urological Association