A Prostate Cancer Foundation memo dated May 24 indicated that the United States Preventive Services Task Force (The Task Force) made a final recommendation against prostate-specific antigen (PSA) based screening for healthy men, asserting that there is "moderate or high certainty that the [test] has no benefit or that the harms outweigh the benefits [of the test]."
The Task Force gave the PSA test a Grade D rating; it applies to men of all ages, but not to men who have been diagnosed with prostate cancer.
The Task Force “says there is little, if any, evidence that PSA testing saves lives and that too many men instead suffer from impotence, incontinence, heart attacks and occasionally death from treatment of tiny tumors that would never kill them.”
A dissenting opinion was published by a number of experts in the care of prostate cancer, including Dr. Patrick C. Walsh, the inventor of the modern day prostatectomy; Dr. Walsh is affiliated with Johns Hopkins Medical Institutions. (Note: The author of this essay sits on the Board of the Johns Hopkins Prostate Cancer Foundation but is not a physician.)
The observations and issues raised in What the Preventive Services Task Force Missed in Its Prostate Cancer Screening Recommendations are numerous and include the following:
The group that authored this dissenting opinion disagrees with the Task Force’s recommendations. The Task Force does not include urologists or cancer specialists. The Task Force used two randomized clinical trials to formulate its conclusions. The results of the trials showed a marked reduction in prostate cancer deaths using PSA tests. Nevertheless, the Task Force indicated this decrease amounted to few lives saved and did not outweigh the harm of screening and diagnosis (false-positive results, associated anxiety and biopsy complications) and the harms related to the treatment of screen-detected cancer. Treatment of localized prostate cancer before it metastasizes reduces mortality compared with observation alone; prostatectomy resulted in a sustained 38% decrease in prostate cancer-specific mortality. Flaws in the aforementioned clinical trials of screening included contamination, too short of a trial period and other procedural problems. Victims of advanced cancer endure more invasive and harmful procedures than those with organ-confined disease. The suffering associated with living with advanced cancer is substantial. High-risk populations have not received adequate consideration; they include families with a high incidence of prostate cancer and men of African descent. Since the widespread use of PSA testing began in the early 1990s, there has been a 40% decrease in prostate cancer deaths and a 75% decrease in advanced disease at the initial diagnosis. Young men who have long life expectancy are at the greatest risk of dying of undetected prostate cancer. Elimination of medical reimbursement of PSA testing would result in much greater diagnosis in the late, and most dangerous, stages of the disease.
The odds of dying of prostate cancer are slim. However, the odds of never dying from prostate cancer are very high with early screening that includes the PSA test.
Men should have this test available and make up their own minds (assisted by their urologists) as to whether to take them. For sure, follow-up tests after a high PSA result are painful and expensive; but it is the only way to determine if the PSA level is a symptom of prostate cancer.
It is difficult to ascertain the ulterior motives of the Task Force. Is it trying to save health care costs? Is it trying to balance the benefits and disadvantages of testing? Suffice it to say, many more men will die a painful death if PSA testing is abandoned before a more reliable test is developed.