A virtual firestorm has erupted with the publication of the US Preventive Services Task Force draft recommendation that healthy men should no longer receive a PSA (prostate-specific antigen) blood test to screen for prostate cancer because “the test does not save lives overall and often leads to more tests and treatments that needlessly cause pain, impotence, and incontinence,” according to a recent NY Times article.
It is well known that the PSA blood test is an imperfect test. However, it is the best one that we have available for early detection of prostate cancer at a stage that is curable, particularly in men ages 45 to 65. This test should not be rejected out of hand because we do not have anything to take its place.
The Prostate Cancer Foundation (PCF), the world’s leading philanthropic funder of prostate cancer research, was founded in 1993 and has raised more than $475 million. It provides funding to more than 1,500 researchers at nearly 200 institutions in 12 countries. PCF advocates for greater awareness of the need for prostate cancer research and greater patient participation in research. In response to the task force’s stance against PSA screening, PCF has made some specific recommendations, which include the following:
1. PSA routine screening should be continued, after the patient is informed of its limitations, until the American Urologic Association clinical guidelines on PSA screening are issued and disseminated. PSA screening is not treatment.
2. The decision to have a PSA test or not should be made between a man and his personal physician based on the man’s age, symptoms, family history, and concerns about prostate cancer.
3. The process of informed patient decision making both prior to and after PSA screening in healthy men should be encouraged.
4. Research should be intensified by the National Cancer Institute with a focus on better early detection tests for lethal prostate cancers.
Hopefully, these recommendations will encourage new public-private research partnerships between the American Cancer Society, the American Urologic Association, the National Cancer Institute, and the Prostate Cancer Foundation. These types of public-private partnerships have the potential to accelerate the discovery, testing, and validation of new biotechnologies for lethal-cancer detection that are superior to PSA screening. Until a new test is developed, however, prostate cancer screening is best served with the continued utilization of the PSA blood test.
The U.S. Preventive Services Task Force report has clearly created a heightened awareness regarding the shortcomings of the PSA test. Certainly, the one positive result would be to encourage the development of a more precise prostate cancer screening blood test. Until that day, the baby should not be thrown out with the bath water. It should not be forgotten that in the pre-PSA era, approximately 80 percent of the patients who were diagnosed with prostate cancer were already in advanced stages of the disease with metastases.
Today, the number of patients who are diagnosed with metastatic disease at the time of initial diagnosis is about 20 percent. Finally, in the past 15 years (the PSA era), the death rate has been reduced from approximately 40,000 men annually to 30,000 men annually in the United States. Screening is the best way to ensure that these trends continue.
Dudley Seth Danoff, MD, FACS, is president and founder of the Cedars-Sinai Tower Urology Medical Group in Los Angeles, a Diplomate of the American Board of Urology, a Fellow of the American College of Surgeons, and the author of two books on men’s health.