An influential federal task force has spoken, but should men listen? Information from the editorial board of the University of California, Berkeley Wellness Letter
January 4, 2012
In 2011, when the U.S. Preventive Services Task Force recommended against routine PSA screening for prostate cancer, many men were surprised and/or angry—similar to the way women felt in 2009 when new mammogram guidelines were released. PSA stands for prostate specific antigen, a protein produced by prostate cells and released into the blood.
Even though the PSA blood test can detect cancer early, it saves few, if any, lives and often leads to treatments causing serious complications, according to the draft guidelines from the Task Force. It concluded that the substantial risks of screening outweigh the benefits, which are small at most, and thus the PSA test should be discouraged. (Note: The guidelines focus only on routine screening, not the use of PSA in men with symptoms or signs of prostate cancer or for its use to monitor cancer treatment. Also, the financial costs of testing and treatment were not considerations in the analysis.)
For most American men who have had PSA tests—and especially the 2 million who have been told they have cancer based on results of screening and subsequent biopsies—this was probably a shock. But actually it wasn't something out of the blue. Three years ago, the Task Force advised against routine PSA tests for men over 75 for the same reasons and, reportedly, it was ready to recommend against routine screening for all men, period. But fears of a backlash (from patients, urologists and politicians) led it to call for more analysis of the data and to postpone the release of the new guidelines.
The value of PSA screening has actually always been questioned. The Task Force has never recommended it, though until now it recently said there was insufficient evidence to recommend for or against it for men age 50 to 75. In 2010 the American Cancer Society stopped advising routine screening and urged more caution; it now simply tells men to talk to their doctors about it. Urological and prostate cancer advocacy groups, which have been boosters of screening, are most vocal in disagreeing with the Task Force's new recommendations. How can a simple early-detection test for cancer not automatically be a great thing?
The prostate, a gland between the bladder and rectum in men, produces seminal fluid. Cancer of the prostate is the second most commonly diagnosed cancer in men (after skin cancer) and the second leading cause of cancer deaths in men (after lung cancer).
The unusual thing about prostate cancer is that the great majority of tumors—especially in older men—remain small, develop very slowly or not at all, do not spread and cause no symptoms. It's estimated that 1 in 6 American men will be diagnosed with prostate cancer, and 1 in 36 will die from it—meaning that it is fatal in about 15 percent of diagnosed cases. Thus, far more men die with prostate cancer than from it. In fact, autopsy studies reveal that one-third of men in their forties and fifties and three-quarters of those over 85 had prostate cancer—usually small and harmless—and never knew they had it (they died from something else).
Age greatly increases the risk of prostate cancer—about 85 percent of cases are diagnosed in men over 60, and 70 percent of deaths occur after age 75. Having a brother or father with prostate cancer more than doubles the risk. Black men are 60 percent more likely to develop it than whites, and twice as likely to die from it. Nevertheless, the Task Force did not recommend screening for black men or those with a family history, for lack of evidence of benefit.
The PSA test merely measures the level of this protein in the blood, not cancer. PSA levels rise as a result of prostate disorders—such as infection (e.g., prostatitis), benign enlargement or cancer—or sometimes for no apparent reason. The test, which is easy to do and inexpensive, was introduced in the 1980s to monitor men already diagnosed with prostate cancer. But doctors soon began using it to screen healthy men.
The Downsides of PSA Screening
Unfortunately, PSA is not a very good screening test. The only way to determine which men have cancer is with a biopsy. Only about 20 to 30 percent of men with elevated PSA turn out to have cancer. (There is debate about what cutoff points should be used to define "elevated" and “normal” PSA.) Moreover, a similar percentage of men with prostate cancer have PSA levels in the "safe" range.
Though experts have proposed ways to improve the interpretation of PSA results—such as assessing PSA level in relation to prostate size and monitoring PSA changes over time—there is still no way to predict with any certainty which low-grade cancers will become aggressive and spread and which will cause no problems.
The biopsies can cause anxiety, pain and, more rarely, infection. But the biggest concern is that abnormal biopsy results usually lead to the treatment of small, slow-growing cancers that would never have become life-threatening—treatment that often has serious adverse effects. (The Gleason score is used to grade the aggressiveness of cancer cells, but more research is needed to determine how much its use reduces mortality rates and overtreatment.) Surgery to remove the prostate and radiation are standard; both treatments often produce erectile dysfunction, urinary problems, incontinence and/or other complications.
Another problem: Choosing a treatment is often confusing, since there is no one "best" option. For older men, "watchful waiting" (or "active surveillance") rather than treatment is often advised. Studies comparing watchful waiting to surgery or radiation therapy have yielded conflicting results.
Why the drop in prostate cancer death rates?
The good news is that death rates from prostate cancer have been declining since 1990. Some researchers attribute the improvement to PSA testing, though this is debated, since better treatments may deserve most of the credit. But if PSA screening is largely responsible, it's surprising that studies have been unable to resolve the debate about it.
Even data suggesting that screening saves lives present a sobering picture. According to some estimates, for every man whose life is prolonged because of PSA screening, somewhere between 30 and 100 men end up being treated for a cancer that was never going to harm them. One-third to one-half of those treated will have adverse effects like erectile dysfunction and urinary incontinence. And about 1 in 200 men die from complications of prostate surgery. Many men with faster-growing prostate cancer will die from it even if PSA screening detects it early and they are treated for it.
PSA Screening Recommendation
At this time, the editorial board of the University of California, Berkeley Wellness Letter does not recommend routine PSA screening—that is, all men should not be automatically tested. The decision is a personal one, and men should discuss the pros and cons of PSA testing with their doctors starting at about age 50, earlier if they are at high risk. Keep in mind, if you decide to be screened, no one knows what screening intervals or PSA thresholds are optimal. Even if you are screened periodically, you should stop at age 75, since further testing is very unlikely to prolong lives.
Studies have shown that when the pros and cons of PSA testing are fully described to men who have not yet made up their minds, they are more likely to decide against it. Such patient/doctor discussions will undoubtedly affect a man's decision about screening far more than advice from the Task Force.
Editorial by John Swartzberg, M.D., F.A.C.P., Chair of the Editorial Board of the University of California, Berkeley Wellness Letter
You may still be confused about PSA screening and whether you (or, if you're a woman, the men you care about) should be tested, even after reading this article from the editorial board of the University of California, Berkeley Wellness Letter. I still debate about it in my head, and with my own doctor.
My doctor (an internist) remains convinced that screening can save the lives of at least a small number of men. We have had several conversations about this, and I've decided to trust her judgment for now, though the Task Force's report has added to my reservations. Should my numbers start to rise, I know I'll be able to work with her to make good decisions (fingers crossed) about what to do—and what not to do.
Other male members of the Editorial Board of the University of California, Berkeley Wellness Letter are split about whether they will be screened. Two won't, several are considering stopping, while the rest will continue to be tested, though some with ambivalence.
You should discuss all this with your doctor. Ultimately, it's up to you how you want to play the odds, but it should be an informed decision. You may decide to be screened, for example, if you place greater value on finding cancer early, despite the uncertain benefits and known risks. In contrast, you may decide against it if you fear that getting abnormal PSA results will land you on the "slippery slope" of overdiagnosis and overtreatment, with all the potential harms that entails.
Many doctors include the PSA test in routine blood work without asking, or even telling, their patients. Some don't mention the potential harms. If your doctor isn't willing to discuss the pros and cons of testing with you, you might look for another doctor. The American Cancer Society and CDC have decision aids to help men decide about prostate testing.
Research continues, and I hope that in the next few years there will be better tests and tools to judge which tumors are likely to advance. That would make PSA screening less controversial.
Adapted from The University of California, Berkeley Wellness Letter (January 2012)