Letter to the editor: PSA screening recommendation needs revision amid rising rate of aggressive disease

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Drs. Navin C. Shah and Vladimir Ioffe share their insight on the Urology Times September 2020 Cover Story, “PSA Screening in Prostate Cancer—The Controversy Continues.”

Re: "PSA screening in prostate cancer: The controversy continues"

We strongly believe, based on our studies of 2396 prostate biopsies (performed due to elevated PSA, abnormal digital rectal examination [DRE], or both) done in 2010-2012, 2018, and 2019, that an annual prostate cancer (PCa) screening should be offered to all men 55 years and older, and especially in high-risk men (African-American [AA] men, those with a family history of prostate cancer, and healthy men 70 years and older).

Our recent study, “A Trend Toward Aggressive Prostate Cancer” (Rev Urol. 2020;22(3):102-109), showed that after the United States Preventive Services Task Force (USPSTF) recommended against PCa screening, there was trend of increasing prostate cancer diagnoses with higher grades despite a decrease in overall biopsy rates. We found that in 2019, compared to 2010-12, the number of biopsies decreased by 45% while the diagnosis of PCa increased threefold.

Prior to 2012, annual PCa screening reduced PCa mortality by 50%. Since the USPSTF recommended against PSA- and DRE-based PCa screening, 50% of primary care physicians do not offer PCa screening.

The American Cancer Society reported 161,360 new cases of PCa in 2017, 164,690 in 2018, 174,650 in 2019, and estimates 191,930 for 2020—an increasing trend. The PCa mortality is also increasing: 26,730 deaths in 2017, 29,430 in 2018, 31,620 in 2019, and an estimated 33,330 in 2020.

Our study identified 3 high-risk groups for increased incidence and grade of PCa: AA men, men with a family history of PCa, and healthy men aged 70 to 80 years old. As the Urology Times article notes, the PLCO screening study was not only contaminated with screening in the control arm but also only enrolled 4% AA men. In the United States, AA men represent 12% of the population, and in large cities, they represent over 30% of the population. In the major European and UK screening studies, only 1% of patients had African heritage. Therefore, the large PCa screening studies underrepresent AA men.

In 2010, Medicare spent $11.8 billion on PCa care and by 2018 this increased up to $15.3 billion, largely due to the treatment of late-stage disease.

Overdiagnosis and overtreatment is significantly reduced due to improved testing and active surveillance.

We agree with the authors, that the USPSTF should reanalyze the long-term data and clearly recommend annual PSA- and DRE-based prostate screening to reduce PCa morbidity, PCa deaths, and the cost of PCa care.

Navin C. Shah, MD, is from Mid-Atlantic Urology Associates, and Vladimir Ioffe, MD, is from 21st Century Oncology, both in Greenbelt, Maryland.