The Last Word on PSA Testing?

Prostate specific antigen or PSA testing has been a mainstay of prostate cancer screening for some time now, and the subject of a LOT of controversy for the last several years.  That's because what has become abundantly clear is PSA screening identifies many, many cancers that may never cause a problem, giving rise to the idea that most men left to their own devices will die with, rather than from, prostate cancer.  BUT once found, treating prostate cancer gives rise to a host of unwanted side effects, including urinary incontinence and erectile dysfunction.  In fact, one study Rick and I talked about a year or so ago on PodMed surveyed men who had undergone treatment for prostate cancer who subsequently said they wouldn't have done so if they had known how troublesome these side effects would be for them.  Hmmmmm.  So now the United States Preventive Services Task Force or USPSTF, has stepped into the fray with a set of guidelines basically saying to men, just say no, as I quip in the YouTube, PSA screening is more trouble than it's worth. The guidelines are published in the current issue of Annals of Internal Medicine, and conclude, succinctly, that "The USPSTF recommends against PSA-based screening for prostate cancer (grade D recommendation)." 

Well.  Game, set, match? Here's some background:  the last time the USPSTF took a look at this issue in 2008, they decided the evidence was inconclusive.  Now they've crunched some pretty sobering numbers, such as the fact that almost 16% of men will be diagnosed with prostate cancer at some point in their lifetime, with a lifetime risk of dying from prostate cancer of about 3%.  The recommendations cite the terms 'overdiagnosis' and 'pseudo-disease' to describe the fact that a) PSA screening results in the detection of many prostate cancers that are asymptomatic, and b) a substantial number of those detected will not progress or will do so so slowly they would never cause a problem.

So how many men have really benefited from PSA screening?  The guidelines estimate the number as very small indeed, since it would include only those men who underwent screening, had a cancer that was detected and treated, and survived.  Their best guess on this number is 1 in 1000.

The flip side to this, of course, is what about false-positive results, consequences of treatment, and the development of the aforementioned conditions that are problematic at best for men once their prostate cancer has been treated?  That number looms large as in the hundreds per 1000 men treated. Check out the paper itself via the hyperlink, above, for the table.

So what's a man to do?  Seems pretty clear to me that unless one is part of a high risk group, perhaps having a family history of prostate cancer or being of African American descent, giving this test a miss sounds persuasive.  Rick confides that he hasn't and has no intention of having PSA screening.  I do think though that it's going to be some time before practices are penetrated and adopt the new guidelines, and in the meantime, we'll still be hearing more about this.

Other topics this week include the dangers of calcium supplements in Heart, a British Medical Journal, the benefits of flexible sigmoidoscopy in NEJM, and diabetic foot ulcer treatment in Clinical Infectious Diseases.  Until next week, y'all live well.


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PSA testing; latest news may open door to “real” prevention. | J … |
June 27, 2012 at 3:16 am

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wyniki na żywo May 27, 2013 at 7:12 am

Nicely put. Thanks a lot.


Qrian June 27, 2012 at 9:39 am

No it isn't.A diet HIGH in dairy products is tughoht to be a possible risk factor for prostate cancer. Note the words high', tughoht' and possible'.And a risk factor is not a cause. Insurance companies regard being male' as a risk factor for having a car crash, but being male doesn't cause car crashes.The greatest risk factor for prostate cancer is getting older. It's extremely rare in men under 50; over 80% of men diagnosed with it are over 65 and half of all cases occur in men over 75. It's so rare in young men that there are no statistics available for the disease incidence in men under 35.


Lauri Ballard June 8, 2012 at 10:27 pm

Excellent! Loved this blog. However, it will be hard to convince people that this test is no longer recommended. I have found that most men do not know of the controversy surrounding the test, I will be discouraging it for my patients going forward.
Can you comment on the gleason score and why this is not helpful in identifying which patients may have an aggressive disease?
Thank you for the podcasts!
Lauri Ballard


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