We are entering a new era when patients will present not with an elevated PSA but rather with symptoms, writes Henry Rosevear, MD.
|Henry M. Rosevear, MD||Dr. Rosevear,|
I have been practicing urology for just under 2 years now and in that period have diagnosed six patients with metastatic prostate cancer at initial presentation. Anecdotally, this is not an uncommon trend. A number of urologists I spoke with at the AUA annual meeting in New Orleans recently reported seeing more prostate cancer patients with late-stage disease at presentation.
All six of my patients were some version of the same story. None of them had either a rectal exam or PSA in years. All had been told that both were useless, and most could even describe the U.S. Preventive Services Task Force (USPSTF) recommendations on PSA screening. All were shocked with the final diagnosis. One is seeking legal advice.
We now have credible evidence that the use of the PSA as a screening test by primary care physicians has declined since the USPSTF issued its "D" grade. At the AUA annual meeting, Dr. Werntz et al showed a 50% decrease in the use of PSA testing by a group of primary care doctors since the USPSTF recommendations were published in 2012. This portends poorly for patients with prostate cancer.
This trend is incredibly important to discuss for a few reasons. First, it is confirmation that we are entering a new era (returning to a previous one?) when prostate cancer patients will walk into your office not with an elevated PSA but rather with symptoms. Just look at the SEER data prior to widespread PSA testing. The number of patients presenting with prostate cancer was not dramatically lower; they simply presented with significantly later stage disease.
Second, this trend stresses the importance of the urologist’s duty to educate primary care physicians that if they’re not going to check PSA, advanced prostate cancer now needs to be included in their differential in all patients who present with either obstructive voiding symptoms or back pain. Further, as is stressed in every major group’s official recommendation on the use of PSA testing, the decision to screen should be a shared decision between the physician and patient. If primary care doctors won't have that discussion with patients, it is our responsibility as urologists to do it. Given the complexity of that discussion, we need a new CPT code (PSA.1?) for prostate cancer screening counseling.
Lastly, while PSA testing as a screening tool is controversial, PSA testing as a diagnostic test is not controversial, and all primary care providers should understand the difference between screening and diagnosis when it comes to the PSA test.
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