“We Must do Better,” A Position Statement Regarding PSA Screening from Dean Foster, MD, PCRI Medical Director

Last May, the U.S. Preventative Services Task Force (USPSTF) triggered a firestorm of debate after issuing its recommendation against the use of the prostate-specific antigen (PSA) blood test to screen for prostate cancer. In her editorial responding to the controversy, Task Force Chair, Dr. Virginia Moyer summarized the committee’s findings with this sentence, “We can do better.” The Prostate Cancer Research Institute (PCRI), while disagreeing with the Task Force’s simplistic banning of PSA, does agree with Dr. Moyer’s conclusion: We can indeed do better.

“We can do better in educating men on the pros and cons of PSA,” explains Dr. Dean Foster, the PCRI medical director and prostate cancer survivor. “However, all the recent controversy is giving men an excuse to tune out about a disease that affects one in six of them. The subject of prostate cancer already makes men uncomfortable.  The controversy over the PSA test gives them one more reason not to pay attention.”

The PCRI encourages men to learn about PSA testing in consultation with their physician. When PSA screening is implemented and elevated levels are detected, further education is necessary before undergoing biopsy. For men with a high PSA, the PCRI currently recommends two additional tests prior to undergoing biopsy: PCA--3, a widely available urine test, and multi-parametric MRI. The PCRI offers free Helpline services to aid men in locating centers offering these services. 

Finally, Dr. Foster concludes: “Men can receive the benefit of PSA screening and still protect themselves from the risk of overtreatment, which is the main factor cited by the U.S. Preventative Services Task Force for giving PSA a “D” rating. The PCRI stands in agreement with Dr. Moyer and the USPSTF in that ‘we all must do better.’  However, PCRI does not recommend simply abandoning PSA screening. Through education, unnecessary overtreatment of the benign type of prostate cancer can be avoided while still using PSA to detect the aggressive form.”

What is a Mindless Biopsy?

MARK SCHOLZ, MD

The recent recommendations by the U.S Preventative Services Task Force to stop PSA screening are articulated as follows:

1.  The magnitude of harms from screening (e.g., falsely high PSA, psychological effects, unnecessary biopsies, over diagnosis of indolent tumors) is “at least small.”

2.  The magnitude of treatment-associated harms (i.e., adverse effects of surgery, radiation and hormonal therapy) is “at least moderate”—particularly because of over treatment among men with low-grade disease.

3.  The 10-year mortality benefit of PSA-based screening is “small to none.”

4.       The overall balance of benefits and harms results in “moderate certainty that PSA-based screening … has no net benefit.”

In the United States a diagnosis of prostate cancer leads to radical treatment 90% of the time, even when men are diagnosed with the Low-Risk form, the type that experts agree can be safely monitored. In fact, since the definitive consensus conference of 2007 in San Francisco stipulated that active surveillance is a reasonable treatment methodology, the use of surgery has increased.  In 2005 approximately 56,000 men had radical prostate surgery.  This number ballooned to 88,000 in 2008.

Surgery is overused because of ignorance about the innocuous nature of Low-Risk prostate cancer and ignorance about the devastating consequences of surgery, which include impotence, incontinence, Peyronie’s disease (crooked penis disease), climactauria (ejaculating urine), urethral scaring and penile shrinkage.

Superstar surgeons are only successful in making 50% of 58-year-old men and 25% of 65 year old men “happy” when happy is defined as staying cured, not leaking urine and having a modicum of erectile function.

A prostate cancer diagnosis is dangerous, even if the terrible risks of over treatment are ignored.  This year the New England Journal of Medicine reported that in first 3 months after a diagnosis of prostate cancer, the rate of heart attack and suicides both increase by about 200%.

Even though the Task Force is entirely correct about the dangers of over treatment, PSA is an inexpensive test that’s proven to saves lives; it is here to stay. In reality, the essence of the problem is not PSA.  The problem resides in the mindsets of the doctors and patients. The doctors doing the biopsies, the urologists who are surgeons, are intensively trained to be action oriented.

The general populace is just as much to blame because the average person knows next to nothing about prostate cancer. When confronted with the shock of a cancer diagnosis, patients naturally assume prostate cancer just as deadly as other cancers.  Surgical removal seems like the most logical way to proceed.

No one has any idea what they are getting into before they are diagnosed. Yet more than a million men rush into a prostate biopsy every year wondering, “Do I have prostate cancer?”  But what are they wondering about?  It is a medical fact that more than half of elderly men harbor some form of prostate cancer. Even men with normal PSA levels will have a positive prostate biopsy 20% of the time.

If you are going to have a biopsy, prepare yourself to have prostate cancer.

So if PSA is abnormal, say between 2 and 10, what should a man do?  First, an individual’s risk of having cancer can accurately be estimated prior to biopsy using a calculator which is available on the web.  The calculator can be accessed by googling “PCPT Risk Calculator.” The real value in this calculator is its capacity to predict the risk of having high-grade prostate cancer, the type of prostate cancer that does require treatment.

In addition, men should consider measuring the size of their prostate gland with MRI or ultrasound. Men with a prostate gland that is in the 30-60 cc range are only one-fourth as likely to have prostate cancer as a man with a prostate that is less than 30 cc. Men with a prostate volume more than 60 cc are only one-tenth as likely to have prostate cancer as a man with a prostate less than 30 cc. High quality imaging with color Doppler ultrasound or 3T MRI can also “see” cancers, especially the larger more malignant types that need treatment.

It’s understandable that people are uninterested in these mundane issues prior to a diagnosis. They think they don’t have it.  The sad fact is that the majority of elderly men do have it.  All it takes is a biopsy to open Pandora’s Box.