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Urology group asserts support for PSA prostate cancer test

Robin Wulffson MD's picture
prostate specific antigen, PSA, controversy, American Urologic Association

Earlier this week, the US Preventive Services Task Force (USPSTF) reported that they had finalized their decision that the prostate specific antigen (PSA) cancer screening test did more harm than good. Despite that opinion, E. David Crawford, MD, chairman of urologic oncology at the University of Colorado Health Sciences Center in Denver, and colleagues spoke out against those recommendations in a late-breaking oral session at the American Urological Association (AUA) 2012 Annual Scientific Meeting in Atlanta, Georgia.

In addition, the AUA responded that they were “outraged” by the USPSTF recommendation and noted that avoiding the test might save money in the short term; however, it will cost more money—and loss of lives in the long term.

The urologic society noted that their position was that “the PSA test provides important information in the diagnosis, pre-treatment staging or risk assessment and monitoring of prostate cancer patients.” However, it acknowledged that not all prostate cancers are life-threatening. Therefore, the AUA recommended that a decision whether to proceed to active treatment or use surveillance is one that men should discuss in detail with their urologists. In addition, Dr. Crawford and his colleagues noted that adopting draft USPSTF recommendations would initially result in $2.4 billion in initial savings; however, many of these men will subsequently developp clinically significant prostate cancer, with total treatment costs far exceeding $2.4 billion, Dr. Crawford said.

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The AUA notes that the specialty of urology is not represented in the USPSTF; there is no urologist on the panel. The AUA noted that strong evidence that PSA testing saves lives. It claims that the randomized trials used by the USPSTF do, in fact, show a benefit to patients. The PLCO Trial was imperfect by the pre-screening contamination of the control arm; however, it reported that, in a group of young men with no other health problems, there was a significant reduction of prostate cancer death rates after a median follow-up of seven years. Furthermore, the AUA noted that the Göteborg Trial also showed a substantial 44% relative risk reduction in prostate cancer mortality occurring in men 50-64 years of age after an average of 14 years. Importantly, the risk reduction occurred in a setting where many of the patients were not aggressively treated for prostate cancer, indicating that the harms of PSA-based screening can, in fact, be minimized by good clinical practice. The AUA noted that a 40% reduction in prostate cancer-specific mortality has occurred during the most recent 20 years of PSA-based screening. Furthermore, updated data from the European Randomized Study for the Screening of Prostate Cancer (ERSPC) has demonstrated that there is a 21% risk reduction in prostate cancer related death associated with screening (up to 29% after accounting for non-compliance). The number of cancers that would need to be detected to prevent one death has now dropped to 37.

The AUA recommends that instead of instructing primary care physicians to discourage men from having a PSA test, the USPSTF should instead focus on how best to educate primary care physicians regarding targeted screening and how to counsel patients about their prostate cancer risk. The association notes that the PSA test has allowed us to move beyond a time when men presented with high-grade, metastatic disease for which there were little or no treatment options other than palliative (supportive care that does not aggressively treat the disease)) care. In its earliest stages, most prostate cancers cause no symptoms; therefore, the task force recommendation to test only men with symptoms of prostate cancer would potentially result in a return to those days when the test was not given. The AUA concluded that discouraging the PSA test when newer tests and diagnostics are not yet widely available does a great disservice to American men.

Reference: American Urological Association

See also: PSA prostate screening test does more harm than good says government panel