PSA Testing Revisited

The United States Preventive Services Task Force announced in its final recommendation Monday that healthy men (at any age) should no longer get screened for prostate cancer with a PSA test because a resulting diagnosis may do more harm than good. While this forum has discussed this issue in some detail in the recent past this final recommendation by the USPSTF strikes me as singularly obtuse in its logic and, in my opinion, has squandered an opportunity to influence how the results of this test should be dealt with my physicians and patients.

Instead of working to change the procedures and improve the way this test is interpreted the task force prefers to shut down testing altogether because some doctors apparently use these results as a business development tool to seduce naive patients into receiving unnecessary treatment. In fact, if you were to read Dr. Virginia Moyer’s op-ed yesterday in USA Today you could easily believe that the actual PSA test itself was the instrument that caused damage. (See http://www.usatoday.com/news/opinion/story/2012-05-22/Preventive-Services-Task-Force/55145238/1) Our own Dr. Otis Brawley (not on the task force) who is the chief medical officer and scientist at ACS (the sponsor of our forum) wrote a op-ed on CNN on Monday indicating that more than a million men in the United States have been treated unnecessarily and been done harm as a result of the test. Other task force panel members have made public statements and appeared on various talk shows castigating the PSA test.

It is interesting to note that none of the present task force members are practicing oncologists or specialize in prostate cancer. While that qualification may not be necessary to draw conclusions from analyses of various studies it seems to me that the force of the recommendation lacks credibility. Dr. Moyer, the chairman of the task force for example, is a pediatrician. Other board members are nurses, public health specialists, community health advocates, and so forth.

The American Urological Association (an organization of doctors who actually specialize in prostate cancer) were outraged by the task force recommendation and issued a statement from their annual meeting in Atlanta that when properly interpreted the PSA test is a valuable tool in diagnosing, staging, and eventual treatment of prostate cancer (http://www.auanet.org/content/media/USPSTF_AUA_Response.pdf)

Certainly many men have been over treated for prostate cancer. We read of men in their 80s receiving surgery for low risk cancer, and most of us have heard our diagnosing physicians tell us that surgery can “get it out of you.” Many men do suffer from incontinence and ED as a result of various treatments that may not have been necessary. Despite this, in my opinion, it is not the PSA test that causes these results but an ill-informed patient at the hands of doctors who too often seem to put the economics of prostate cancer ahead of patient welfare and quality of life. The focus of the task force should have been, in my lay opinion, directed at family physicians and urologists who push for biopsies at almost any PSA reading instead of putting the PSA test in a comprehensive context with other physical symptoms, DRE results, family history, a PSA history, whether or not BPH is present, the potential for a UTI, and reminding the patient to avoid sexual relations for a few days before the blood draw. GPs tell us to avoid eating before having our blood drawn for blood sugar levels at our annual physicals but they never seem to tell us to avoid sex before the blood draw as well. (Sexual release within 48 hours of a PSA test will cause an abnormally high PSA reading).

At the end of the day I don’t think the USPFTF recommendations will amount to much. You may recall similar outrage at this committee’s recommendation about mammograms a few years ago and their recommendations for women at certain ages to avoid the test have been largely ignored. Immediately after the task force made its findings public, the Obama administration released a statement that Medicare would continue to cover the cost of the PSA test. If Medicare continues to pay (and I suspect most insurance companies will follow this standard as well) doctors will continue to do the test. Men do need to inform themselves about what the PSA test means to them and several other related factors but the task force avoided addressing these issues so nothing much will happen. A wasted opportunity all around.

K