The United States Preventive Services Task Force (USPSTF), an independent panel appointed by the Federal cabinet-level Department of Health and Human Services (DHHS), is preparing a recommendation which would eliminate prostate cancer testing (PSA) for all men. The rationale cited by the government panel is that there is moderate or high certainty that PSA testing has no net benefit or that its harms outweigh its benefits. (It should be noted that the panel did not include a urologist nor a medical oncologist.) The basic question involved in this recommendation is whether or not routine PSA testing saves men’s lives. Prostate cancer patients, survivors and advocates are being urged to voice their opinion about this recommendation to their Senators and members of Congress. Additionally, the USPSTF is accepting public comments on the new recommendations for the next four weeks. Links to communicate your opinions can be found in the October 7th and October 12th ZeroHour Newsletter from Zero-the Project to End Prostate Cancer.
Two major conflicting medical studies, one American and the other a European study, are being cited as evidence for/against this recommendation. These studies and their conclusions have been summarized by Dr. Patrick Walsh from the James Buchanan Brady Urological Institute – Johns Hopkins University on its website. (It should be noted that this institute at Johns Hopkins has been named the #1 choice for urology for the last 21 years consecutively by the annual survey in U.S. News and World Report. Dr. Walsh pioneered the development of the surgical nerve-sparing techniques whereby nerves controlling erections and urination are spared from damage during radical prostatectomies.) The European study was carried out in seven European countries involving 162,000 men who were randomized to PSA screening every four years versus no screening. After fourteen years of follow-up, “there was a 20% decrease in deaths from prostate cancer in the group of men assigned to screening.” Further examination of the data leads to a conclusion that the decrease in prostate cancer deaths could be as high as 27%. According to Dr. Walsh, “this reduction in death from prostate cancer is similar to the 30% reduction in mortality from breast cancer in women who undergo mammography and the 33% reduction in prostate cancer mortality that occurred in the United States between 1994 and 2003 following the introduction of PSA screening. Thus, the results from the European study support other findings and unequivocally demonstrate that PSA testing can save lives.” The second trial was carried out in the United States and was half the size of the European trial. “It compared screening with PSA every year for six years with no screening thereafter versus no planned screening. It showed no improvement in prostate cancer mortality at 7 years.” The reader is encouraged to review Dr. Walsh’s comments on these trials at the Brady Urological Institute website. He concludes that “if you are a healthy man age 55-69 who does not want to die from prostate cancer, the European trial provides conclusive evidence that PSA testing can save your life.”
What could occur if PSA screening was less accessible? What would be the options for a middle-aged man? A physician and close friend commented as follows. There are no specific symptoms whatsoever of the early stages of prostate cancer. The signs of early prostate cancer are indistinguishable from the signs of benign prostatic enlargement that commonly occurs as we age–namely, a weak or intermittent urinary stream, hesitancy (difficulty starting the flow of urine), straining, dribbling, having to get up at night to urinate, and the need to strain during urination. More serious signs–that increase the odds of a cancer being present–include blood in the urine and bone pain especially in the pelvis, ribs, or back. Any of the symptoms mentioned above in a man over 40 years old should prompt a visit to a physician. If cancer were present, blood in the urine and bone pain would seem to indicate the disease had advanced considerably by this point if more routine PSA screening had not been available.
As with any treatment, there are both benefits and risks. In the pre-PSA era, approximately 80% of patients who were diagnosed with prostate cancer, were already in advanced stages of the disease with metastatic cancer. Today, the number of patients who are diagnosed with metastatic disease at the time of initial diagnosis is around 20%. In the past 15 years, the prostate cancer death rate has been reduced from 42,000 annually to 33,000. On the other hand, according to the Prostate Cancer Foundation’s NewsPulse, PSA screening leads to biopsies wherein less than half of the patients who are biopsied each year are subsequently diagnosed with cancer. In addition, recent studies show that approximately 7% of men over 65 who have prostate biopsies are hospitalized within 30 days of the procedure, primarily due to infections according to the October 4th issue of the National Cancer Institute Bulletin.
Treating men over 70 aggressively for prostate cancer when instead their cancers might never become life-threatening is a practice that needs to be reduced. Instead, concentrating treatment on younger prostate cancer patients should be encouraged.
Personally, at the age of 54, my own cancer was discovered by a biopsy which was dictated by a moderately-consistent PSA of 4-5 ng/ml. I underwent a radical prostatectomy in 1995 at Johns Hopkins which resulted in virtually none of the side effects such as incontinence and impotence. This is indicative of the Johns Hopkins surgical nerve-sparing skills. (This website tells my entire story and lessons learned.)
There are more positive recommendations that could be made in the case of prostate cancer screening. PSA screening in patients should be more selectively targeted thus reducing over-testing and risks from over-treatment. Annual PSA screening may be better utilized as a baseline test and a series of tests over time to determine the rate of change of the PSA values with time (PSA velocity). Another useful test is prostate density, which refers to the PSA divided by the estimated weight of the prostate. A PSA of 5 ng/ml in a small prostate is more likely to indicate a cancer than a PSA of 8 ng/ml in a very large prostate. Also, through joint public-private research partnerships, government scientists such as those at the National Cancer Institute (NCI) of the National Institutes of Health (NIH) could focus stronger efforts on better early detection tests of lethal prostate cancers. Above all, validated biomarkers that are prevalent in most prostate cancers and could be detectible in urine or blood tests are sorely needed in order to detect and determine the aggressiveness of prostate cancers. For example, the DNA markers TMPRSS2:ERG gene fusion and PCA3 (prostate cancer antigen DNA) are expressed at high levels in 95 percent of prostate cancers. The gene fusion TMPRSS2:ERG occurs in 50 percent of prostate cancer patients. This two-gene DNA urine test is ultra-specific to prostate cancer and prostate cancer only.
Thank you for reading this most urgent blog. Please express your opinions on PSA screening to your senators and congressional representatives as well as to the USPSTF government panel.