The following is a guest blog post by Alan Cassels.
A urologist got an opinion piece, “Bring Back Prostate Screening,” published in the New York Times last week. The author writes: “men should not wait for a government agency to tell them what’s best. My own strongest recommendation is that men insist on a baseline PSA test while in their 40s.” He could have also written, “Men should not wait for what the American Urological Association guideline panel recommends, since that panel “does not recommend routine screening in men between ages 40 to 54 years at average risk.”
That “government agency” rhetoric gets real tired after all this time, especially when it’s one-sidedly incomplete.
Yes, in May 2012, the United States Preventive Services Task Force gave the PSA test a definitive thumbs down due largely to the growing recognition of overdiagnosis. The USPSTF said that while the “benefits of the test were small”, the harms of this simple blood test which often begins a cascade of interventions that can end in “erectile dysfunction, urinary incontinence, bowel dysfunction, and a small risk for premature death.” This recommendation probably contributed to the significant drop in the numbers of men being tested for prostate cancer after the publication of the much publicized US Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, which found no statistically significant effect of PSA screening on prostate cancer deaths after 13 years.
About the same time as the New York Times published the urologist’s commentary, other articles pointed out to other recent fallout from, and followup on, the concerns about overtreatment of prostate cancer.
MedPage Today reported on a study in the Journal of the American Medical Association that found that “Three out of four older men with low-risk prostate cancer opted for active surveillance during a 4-year period ending in 2013, according a large prostate cancer database.” Active surveillance is the new preferred term for used to be called watchful waiting. The researchers wrote:
“In this analysis of a longstanding national registry, we found that after years of overtreatment for patients with low-risk prostate cancer, rates of active surveillance/watchful waiting for low-risk disease increased sharply in 2010 through 2013,” Matthew R. Cooperberg, MD, and Peter R. Carroll, MD, of the University of California San Francisco, wrote in conclusion.
“The magnitude and speed of the changes suggest a genuine change in the management of patients with prostate cancer in the United States, which could accelerate as more clinicians begin to participate in registry efforts,” they added. “Given that overtreatment of low-risk disease is a major driver of arguments against prostate cancer screening efforts, those observations may help inform a renewed discussion regarding early detection policy in the United States.”
The MPT story had this noteworthy ending:
Perhaps overlooked in the focus on active surveillance, use of radiation therapy decreased during the later years of the study period. The finding is notable, said Willie Underwood, MD, of Roswell Park Cancer Institute in Buffalo, N.Y., because it coincided with a trend toward urologist-owned radiation therapy centers, which caused some concern about financially motivated overuse of radiation therapy.
Let’s not forget the big elephant in the room. Many who recommend PSA testing tend to generally earn their living removing or radiating prostates. And all this treatment creates a huge economic burden where the total cost of care in the US was estimated at about $12 billion in 2010. As this article in the American Journal of Managed Care indicates, high-tech treatments like intensity-modulated radiotherapy (IMRT) and robotic surgery are likely being overused “because many healthcare providers are still operating in a fee-for-service environment.”
Meantime, a story in Urology Times reported on an analysis in CA: A Cancer Journal for Clinicians (2015; 65:264-82). Excerpt:
“Despite increasing use of active surveillance and watchful waiting in men with low-risk, localized prostate cancer, expectant management remains underused. …
Most low-risk patients still undergo surgery or radiation with attendant risks of long-term side effects such as erectile dysfunction and impaired urinary function, they note, even though expectant management has been shown to result in excellent long-term cancer-specific survival with minimal morbidity.
As many as 40% of patients may currently be overtreated, said senior author Mark Litwin, MD, MPH, of UCLA.
… “Active surveillance is a viable approach for most men with low-risk prostate cancer, and its broader adoption has the potential to stop the overtreatment of men with indolent lesions and redirect resources to men with more serious cancers,” the authors concluded.”
Perhaps it’s good to say that physicians are now more open to alternative ways to treat whatever it is they find with your high PSA reading and that active surveillance/watchful waiting is being offered. But really ask yourself, if it is clear that the PSA test turns many healthy men into patients, and places a sword of Damocles over their heads, where fear always looms, does PSA screening even fit the “First do no harm” credo of medical professionals?
In my mind, you can’t separate over-treatment from over-diagnosis. As the CA journal article states, “In the PSA screening era, it is estimated that as many as 4 in 10 men are overdiagnosed with—and often are over treated for—nonlethal prostate tumors.” That’s a lot of harm.