Task Force sticks to its guns on PSA screening; urologists respond strongly, quickly

May 22, 2012

Article

The highly contentious issue of prostate cancer screening heated up during this week's AUA annual meeting when the United States Preventive Services Task Force (USPSTF) announced on Monday that it would not change its grade "D" recommendation on PSA screening for prostate cancer.

Editor's note: This article has been updated to include links to statements from leading physician and patient groups on the recent USPSTF recommendations as well as other links relevant to this topic (see below).

The highly contentious issue of prostate cancer screening heated up during this week’s AUA annual meeting when the United States Preventive Services Task Force (USPSTF) announced on Monday that it would not change its grade “D” recommendation on PSA screening for prostate cancer.

The Task Force recommends against PSA-based screening for all men, regardless of age.Reaction to the final recommendation, which will be published online in Annals of Internal Medicine (May 22, 2012), came swiftly from organized urology and AUA meeting attendees.

"The AUA is outraged at the USPSTF’s failure to amend its recommendations on prostate cancer testing to more adequately reflect the benefits of the PSA test in the diagnosis of prostate cancer," AUA President Sushil I. Lacy, MD, said. "It is inappropriate and irresponsible to issue a blanket statement against PSA testing, particularly for at-risk populations, such as African-American men.

"Rather than instruct primary care physicians to discourage men from having a PSA test, the Task Force should instead focus on how to best educate primary care physicians regarding targeted screening and how to counsel patients about their prostate cancer risk."

In October 2011, the USPSTF recommended against routine PSA-based screening because it said it results in little or no reduction in prostate cancer–specific mortality and is associated with harms related to subsequent evaluation and treatments, some of which may be unnecessary. The draft recommendations underwent a period of public comment in which several groups, including the AUA, sharply criticized them.

"Until there is a better widespread test for this potentially devastating disease, the USPSTF is doing a great disservice to the men worldwide who may benefit from the PSA test," Dr. Lacy said.

Despite the objections of the AUA, other physician organizations, and patient advocacy groups, the USPSTF did not change its position.

“Many people who commented on the recommendations urged the Task Force to change the recommendation to a grade 'C,' meaning physicians could provide the test to patients who request it. However, no new evidence was presented," the USPSTF said in a statement. "The recommendation remains unchanged."

The timing of the final recommendations’ release during the AUA annual meeting brought an immediate response from organized urology. The AUA brought together representatives of six leading urology and patient advocacy groups for a Monday evening news conference, where speakers unanimously condemned the USPTF’s position.

"I think we would all agree that the appropriate use of PSA and DRE, combined with informed consent, especially in at-risk populations, does indeed reduce deaths from prostate cancer," said John Lynch, MD, a member of the AUA Board of Directors and a prostate cancer survivor. "It is a disservice to men to deny them the opportunity for potential treatment and cure, when necessary, for a disease that affects one in six over the course of their lifetime."

"We are deeply disturbed that the Task Force failed to amend their recommendations to more appropriately address the use of the PSA test," added David Penson, MD, also representing the AUA. "The AUA, along with other major medical groups-including the American Cancer Society-believes that men should talk to their doctors about their individual prostate caner risk, and that PSA testing is an individualized decision that should happen in the context of that discussion."

The announcement also drew strong reaction from urologists interviewed by Urology Times at the Georgia World Congress Center.

J. Brantley Thrasher, MD, of the University of Kansas Medical Center, Kansas City, called the recommendations "short sighted."

"I don’t think you can ignore the fact that since PSA screening started, we’ve seen a 40% drop in prostate cancer mortality in this country," Dr. Thrasher told Urology Times.

Dr. Thrasher said he did not think the recommendations would cause urologists to change the way they practice.

"I think that most urologists are doing what the guidelines recommend, which is getting the PSA starting at the age of 40. They are putting the high-risk patients on the radar screen earlier and getting PSAs and digital rectal examinations earlier," Dr. Thrasher said.

"What I worry about more is not the practicing urologist as much as the patients themselves, third-party payers-people that may be looking at this data that don’t know the information like we as urologists do."

Robert Dowling, MD, a urologist from Fort Worth, TX, was also asked how he expected urologists to respond to the recommendation.

"Because it included two studies that reached slightly different conclusions, I think that the urology audience is going to get behind the evidence that supports their current practice, which is to screen selected patients for prostate cancer and use the PSA as a screening tool, based on patients’ life expectancy and comorbidities, after counseling them thoroughly about the pros and cons," Dr. Dowling said.

"I think the recommendation does highlight the importance of counseling patients about the possibility of detecting both significant and insignificant cancers.”