Routine PSA Screening for Prostate Cancer
Oakland, CA July 13, 2013. Dennis R. Hill M.D. Radiation Oncologist at the Alta Bates Summit Medical Center in Oakland, CA reports that although the United States Preventative Services Task Force (USPSTF) has recommended that PSA screening for prostate cancer NOT be done on any man of any age this recommendation is not without controversy. The USPSTF shook up the status quo last July when it advised against PSA testing with averagerisk men of any age who had no prostate cancer symptoms.(1) In May 2013, the American Urological Association (AUA) released new clinical guidance on the early detection of prostate cancer.(2) The USPSTF panel that developed the 2012 recommendations did not include representation from the urology community. The American Urological Association (AUA) feels that as the physicians most experienced in the diagnosis and treatment of prostate cancer, urologists should be involved in the development of prostate cancer screening recommendations to ensure that the guidance is evidence-based and also targets the preferences of individual patients. The AUA strongly supports the inclusion of specialists on the USPSTF (as outlined in the USPSTF Transparency and Accountability Act) that develop recommendations that impact patient care. The AUA remains in disagreement with the USPSTF in its general statements against the use of PSA testing in all men. They support a man’s right to be tested for prostate cancer – and to have his insurance pay for it, if medically necessary – if, in fact, he decides to do so following a detailed conversation with his physician about the benefits and harms of screening. The AUA continues to support the use of the PSA test. However, PSA-based screening without clearly targeting those who are most likely to benefit from testing does result in harms, including over diagnosis and overtreatment. All involved professionals have to take a more targeted approach to minimize these harms. The AUA feel that men ages 55 to 69 who are in good health and have more than a 10- to 15-year life expectancy should have the choice to be tested and not discouraged from doing so.
There is general agreement that early detection, including PSA screening, has played a key part in decreasing prostate cancer mortality. My own experience goes back to before PSA screening was widely available (PSA testing became widely available in the late 1980’s). During this time before PSA testing I was practicing external beam radiation and the majority of prostate cancer patients we saw had locally advanced disease and were difficult to cure. Symptoms are rarely a first sign of prostate cancer. Most are asymptomatic even if they have advanced local disease. Even if the patients that do have symptoms they are often related to the benign enlargement of the prostate not the cancer. I know for a fact that I have been seeing prostate cancer in a much earlier stage since the advent of PSA testing. It may be that we are a victim of our own success. The prostate cancer mortality dropped very noticeably in the 1990s after the advent of PSA testing.
The cure rates with early stage low risk disease are high and essentially the same (over 90%) whether the treatment is radical surgery, external beam radiation, permanent seed implant or high dose rate brachytherapy. The USPSTF says there are harms from overtreatment but that depends on the type of treatment given. High Dose Rate Brachytherapy has a very low complication rate compared to the other modalities. There are essentially no rectal complications, no incontinence and a low percentage of erectile dysfunction.
My feeling is more consistent with the AUA position. If the man is healthy, between 55 to 70 years old, I think he should have a screening PSA test every two years. Men at high risk for disease, such as a positive family history, should be encouraged to discuss their individual case with their doctor, regardless of age.
About Dennis R. Hill MD
Dr. Hill has been doing High Dose Rate Brachytherapy exclusively since 2004. He has done over five hundred High Dose Rate Prostate Brachytherapy implants and has published scholarly articles on the subject. His office is located at: Dennis R. Hill MD 3012 Summit Street Suite 2675 Oakland, CA 94609 510-869-8875 firstname.lastname@example.org and his website is hdrprostatebrachytherapy.com, which includes a quiz to determine if a patient is a candidate for HDR Prostate Brachytherapy.