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The USPSTF Recommendation on PSA Screening: Our Readers Have Spoken

Feature |
July 12, 2012

The USPSTF Recommendation on PSA Screening: Our Readers Have Spoken

  1. Allan S. Brett, MD

Results of an online poll and reader feedback about prostate-specific antigen screening

  1. Allan S. Brett, MD

After the U.S. Preventive Services Task Force (USPSTF) published its final recommendation opposing prostate-specific antigen (PSA) screening, we conducted an online poll of readers' reactions. A total of 177 readers responded to the question “Please choose the statement that best fits your reaction to the USPSTF recommendation against PSA screening.”

As shown in the table, 78% of respondents agreed with the USPSTF recommendation, but a substantial proportion still will offer screening selectively. I'm guessing — based on informal discussions with other physicians — that some of these responses reflect concerns about litigation for failure to diagnose cancer.

Many readers shared their perspectives by posting “reader remarks” in response to our recent summary of the USPSTF recommendation (JW Gen Med Jun 7 2012). One reader will continue to screen because she “has probably saved the life” of several men with screening. She might be right: Even skeptics must concede that individual lives occasionally are saved by screening. After all, if enough men undergo prostatectomy, somewhere in the mix are men who eventually would have died of prostate cancer. But, the important question is this: How many people must undergo screening, biopsies, prostatectomies, and radiation therapy to benefit one person? The Task Force concluded that the number needed to screen (NNS) and number needed to treat (NNT) are too high and result in adverse outcomes for too many people, whereas advocates of screening believe otherwise. Nothing is wrong with arguing that a particular NNS or NNT is too high, as long as we remember that selection of “appropriate” cutoffs are value judgments and not scientific truths.

Another reader entitled his remark “Can't tell who is saved.” He correctly implies that when a man survives (cancer-free) after treatment for PSA-detected cancer, we can't determine whether his particular life was saved by screening. From the European randomized screening trial (JW Gen Med Mar 14 2012), we can infer that roughly 1 of every 30 patients who received treatment for screening-detected cancer had his life extended, but we don't know which particular man was “saved” and which 29 underwent treatment unnecessarily.

Several respondents claimed that mismanagement of PSA results and overtreatment of patients with low-risk prostate cancer — and not PSA screening — are the real problems. In my view, both the PSA test and overtreatment are problematic. No screening test has perfect sensitivity and specificity, but PSA test accuracy is especially poor: Fully 25% of men with PSA levels between 2 and 4 ng/mL have prostate cancer (JW Gen Med Jun 8 2004), and many men with PSA levels between 4 and 10 ng/mL don't have prostate cancer. Sensitivity and specificity can be refined somewhat by using age-specific cutoffs, change in PSA level over time, or other variations; but so far, these other approaches have not been tested rigorously in controlled studies. Management approaches are all over the map because clinicians don't quite know what to do when PSA levels go up a little: Biopsy now? Repeat in 1 year? Repeat in 6 months? Give antibiotics for “prostatitis,” and repeat in 1 month? And, regarding overtreatment of men with low-risk cancer, thoughtful urologists have told me, “I agree that we overtreat. But if a patient who doesn't really need surgery says, ‘I want my cancer treated,' what are we supposed to do? If we don't do the surgery, he'll go elsewhere.”

Another reader suggested that PSA screening is most beneficial in men older than 75. However, in the European screening trial, among men 70 or older at the time of randomization, researchers noted a trend toward higher mortality in screened versus nonscreened men. And, in the largest treatment trial (prostatectomy vs. watchful waiting in men with localized cancer; JW Gen Med Sep 16 2008), prostatectomy was associated with lower mortality only in men younger than 65.

One final interesting comment: A physician reader notes that when patients ask him whether he gets PSA tests himself, he replies that he does not, even though “my father and father-in-law had prostate cancer.” In some clinical encounters, it might be appropriate to share one's personal medical decisions. But, I believe that when patients ask about PSA testing, physicians should explain why they agree or disagree with screening and leave their own healthcare decisions out of the discussion.

Reader Comments (13)

DR Kelsey

Let's put this in perspective. Recent reports on preventing heart attacks by chronic use of statins generally estimate between 100 and 250 patients have to be treated to prevent ONE CV event. So screening 30 men for early detection of prostate cancer in one patient is, by comparison, more effective and cheaper. The issue really should not be whether to test or not but (1) to develop a more reliable test and (2) better biopsy and treatment methods. And as far as I have seen, nobody in the hype around this subject has mentioned the predictive application of free PSA compared to total PSA which, according to printouts from the labs, has some statistical correlation to cancer.

Competing interests: None declared

Michael G. Vesselago

Dear Dr. Brett,

Thank you very much for using the reader remarks as an opportunity to reflect on some very important issues within the practice of medicine. Your clarity and incisive thinking, articulateness (not to mention excellent writing style) and thoughtfulness are welcome.

I appreciate also the quality of editorial leadership reflected in the articles written by your reviewers.

Sincerely Yours,

Michael G. Vesselago

Competing interests: None declared

David Gorelick

Regarding the comment made by Dr. Holtz -"let those who want the test pay for it". Patients commonly say that it is just a blood test, what's the harm? This after I just explained how false negative and false positive results are misleading, true positive results many times lead to interventions that cause harm - impotence, incontinence, pain, infection, etc. without the promise of improved outcome. Sorry to beat up the point, but my question is: If the patient pays for the test, who pays for the unproven, harmful, expensive interventions? Who pays for the artificial urethral sphincter implant? Not to mention all of the urology office visits for the complications and side effects of the interventions. These are mainly folks on Medicare - we are paying for it. I don't agree with the premise that it is just a test, or let them pay for the PSA. Until the patient is required to flip the bill for the whole package I suggest we follow EBG and accept the fact that a small percentage will suffer and die because of not screening. When looking at population screening you need to take that into account, we can't afford to save everyone - from a clinical, ethical, emotional, or financial point of view.

Competing interests: None declared

Bernard A. Yablin

Who has read the article and editorial in the May 2012 issue of Ann.Int.Med--they still raise relevant questions on the issue.

Competing interests: None declared

H.A. Holtz

I think reasonable people can agree with both these propositions: the PSA test has significant flaws and this country can't afford to pay for widespread programs that just might work. Let those who want the test pay for it. The political right will have government out of the prostate screening business and reduce the deficit, the left can say that smart government can work, special interests will scream either way. It would free primary care physicians from many "PSA talks" and from unfair liability risks. Who knows- it may even lead us to a path where we leave something for our children?

Competing interests: None declared

Norman M. Canter

The problem is not the test but the experience and intelligence that is required for proper treatment or lack of it when the results are known. Prostate cancer should be treated by experienced experts and not casual urologists. If the patient demands treatment where none is indicated, morality and ethics dictates referral to a tertiary center and not accession to the pressure of the uninformed patient. The PSA is a piece of information that needs intelligent consideration as part of the whole picture. Playing ostrich has no honored place in medical practice.

Competing interests: None declared

David J Magee

A very helpful summary of the evidence combined with insights from physicians' experiences. I have more sympathy with the physician who was asked, 'What would you do about your own PSA?' This is not an easy question to dodge and the answer of a trusted physician at least gives some perspective for the layman in discussing this confusing topic.

Competing interests: None declared

Osvaldo F Gasc

I believe that if the PSA is over 4 and the tactile rectal exam is positive, biopsy should be performed, which will resolve doubt about the diagnosis

Competing interests: None declared

Margaret A Conte

I live in Delaware, currently 13th in the nation in cancer incidence (we previously had the dubious distinction of being 1st). I offer my patients ANY appropriate cancer screening. I do tell men about the current thinking about PSA, and about the risks inherent in living in a state with extremely high cancer prevalence. Most patients choose screening. Now, don't misinterpret my statements. I do REASONABLE cancer screening e.g. Pap smears at recommended intervals, mammograms usually yearly after age 40 (I rejoice when I see a negative breast biopsy). I never recommend CA-125 or CEA as a screening test.

Competing interests: None declared

David R Mehr

Frankly I see nothing wrong with telling my patients that I decided for myself not to get the PSA test. I feel the same about telling my patients that I have had two colonoscopies and except for the prep, it was painless for me (not that that is guaranteed for all). I think sharing personal experience if it is comfortable and fits the situation is a perfectly appropriate communication technique. I also talk about my personal experience of hospice with my parents when that fits as well.

Competing interests: None declared

Robert D Hoffman

As a primary care physician - a large proportion of my older male patients request PSA testing. I explain the issue and that it is not recommended. They respond that the urologist sends them routinely so it just will save time to get the referral from me. Until Urologists follow the recommendations - the PCPs will not be able to stop the flood of unnecessary PSA testing.

Competing interests: None declared

Jack Kaye

I had to chuckle at the statement: "One final interesting comment: A physician reader notes that when patients ask him whether he gets PSA tests himself, he replies that he does not, even though "my father and father-in-law had prostate cancer."" It suggests a belief that he inherited risk from a relative by marriage - unlikely.

Competing interests: None declared

David Gorelick

I know we have learned to avoid bringing our personal lives/information into the discussion with patients, our decisions and advice should be objective. However, if you have a relationship with your patients for years and they are staring at a life decision, they look and ask "what would you do for your mother" is the typical question. Well, the real question is what would I do for myself - that is what hits home in my opinion. If we did take a little bit of our own feelings and share them with patients and families, maybe we would have fewer 95 year-old patients spending the last 3 weeks of their lives in the ICU on life support when there is no way we would want it for ourselves. I digress, but emphasize my point that sharing with patients that I refuse to get prostate screening is important. I still absolutely give them the party line that with the risks/benefits, the data as it is, and make it clear that it is their choice. But, after the discussion if the patient is looking like the deer in the headlights, not having a clue on how they can make a "medical" decision for themselves, I bring up "consider that I am over 50, if you want to know what I do for myself....."

Competing interests: None declared

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