Recommendation against PSA test goes too far

A draft recommendation by the U.S. Preventive Services Task Force calling for an end to routine PSA testing for healthy men age 50 and older goes too far, says a prostate cancer expert at the Siteman Cancer Center at Washington University School of Medicine and Barnes-Jewish Hospital in St. Louis.

“Mass screening is not the way to go,” says Gerald Andriole, MD, chief of urologic surgery, who acknowledges that widespread testing has lead many men with slow-growing tumors to be over diagnosed and over treated with aggressive therapies. “We have to take a more nuanced approach to determine which men should be screened in the first place, how frequently they should be tested, and whether their cancer warrants therapy.”

In recommending against routine PSA screening, the task force says that the test does not save lives and, when positive, often leads to invasive biopsies and treatments such as surgery or radiation therapy, with side effects that can include incontinence and impotence.

But Andriole, who also is the principal investigator of the National Cancer Institute’s Prostate, Lung, Colorectal and Ovarian (PLCO) screening trial, argues that it would be a mistake to universally dismiss the PSA test. Rather, he says the decision to screen should be left up to patients and their doctors, who should take into consideration a man’s overall health, age and other risk factors.

Discouraging men with a high risk of dying from prostate cancer – particularly African-Americans and those with a family history of prostate cancer – from getting a PSA test would be misguided, he adds.

For men who choose to have a PSA test, Andriole urges caution if the test is abnormal. Doctors, he says, often do not need to rush to perform biopsies or recommend aggressive treatments because most prostate tumors grow slowly. In many cases, “active surveillance” may be practical, which involves periodic PSA tests and biopsies to monitor tumor growth rather than opting for immediate aggressive treatment.

Ending PSA screening all together would mean a return to the “pre-PSA” era when about a third of prostate cancers were advanced and incurable at the time of diagnosis.

Preliminary results of the PLCO trial, published in 2009 in the New England Journal of Medicine, indicated that routine PSA screening does not reduce deaths from prostate cancer among men ages 55-74 who had been followed for up to 10 years.

But Andriole says that a close look at younger, healthy men in the study showed an improvement in prostate cancer mortality among those who had PSA tests and digital rectal exams. With longer follow-up, there may be additional benefit to screening for younger men and men who are known to have a high risk of dying from the disease. Updated results of the study are expected to be published later this year.

“Routine annual PSA screening is not necessary for most men,” Andriole says. “But men with a high risk of dying from prostate cancer – particularly African-Americans and those with a family history of prostate cancer – should still be screened.”

Prostate cancer is the second most common cancer among men, after skin cancer. In 2010, nearly 220,000 U.S. men received a diagnosis of prostate cancer and an estimated 32,050 died of the disease.

Washington University School of Medicine’s 2,100 employed and volunteer faculty physicians also are the medical staff of Barnes-Jewish and St. Louis Children’s hospitals. The School of Medicine is one of the leading medical research, teaching and patient care institutions in the nation, currently ranked fourth in the nation by U.S. News & World Report. Through its affiliations with Barnes-Jewish and St. Louis Children’s hospitals, the School of Medicine is linked to BJC HealthCare.