PSA controversy has practical implications

December 12, 2014

The authors of a recent study should be commended for exploring a large national database in an attempt to understand contemporary prostate cancer screening and treatment practices.

Dr. AlbertsenScreening for prostate cancer with the PSA test remains extraordinarily controversial. In 2012, the U.S. Preventive Services Task Force recommended against any PSA testing because the panel felt that the potential complications associated with biopsy and treatment that occurred in over 10% of men screened were not adequately balanced by the potential gain in averting one death per thousand men screened over a 10-year period (Ann Intern Med 2012; 157:120-44).

The revised AUA guidelines published last year were more sympathetic to screening and suggested that men age 55-70 should discuss prostate cancer screening with their physician because of the potential to prevent prostate cancer mortality (J Urol 2013; 190:419-26). Data from the updated European Randomised Study of Screening for Prostate Cancer trial showed a relative risk reduction of 21% and an absolute reduction of one death averted per 781 men invited for screening over 13 years of follow-up (The Lancet 2014; 384:2027-35). Data from the updated Scandinavian Prostate Cancer Group Study Number 4 trial showed a relative risk reduction of 56% and an absolute risk reduction of 11% over 18 years of follow-up among men undergoing radical surgery for newly diagnosed disease (N Engl J Med 2014; 370:932-42). Surgery benefited primarily younger men under age 65 with moderate-grade disease.

The research by Rao et al suggests that this controversy has had practical implications. They observed a decline in the rate of prostate biopsy in the Veterans Health Administration system over the past decade. This finding would be welcome if the decline in prostate biopsies was primarily observed in men older than age 70 or among men with significant medical comorbidities. These are the men least likely to benefit from PSA testing.

These findings, however, could raise concerns if they reflect a complete cessation of PSA testing. Men age 55-70, especially those with intermediate and possibly high-grade disease, have the most to gain from PSA testing. Men found to have minimal low-grade disease should be offered active surveillance. This treatment pathway, however, would result in an increase in prostate biopsies because of the customary practice of confirming an initial diagnosis and using prostate biopsy as a way of monitoring for disease progression.

The authors should be commended for exploring this large national database in an attempt to understand contemporary screening and treatment practices.

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