We believe that if the USPSTF recommendation is adopted, it will result in a public health tragedy within 5-10 years. Consider the SEER data where-in from 1972-1991 (pre-PSA) deaths from prostate cancer increased 27% from 30.97/100,000 men to 39.31/100,000 men, while from 1991-2009 (PSA era) the death rate decreased 44% to 21.9/100,000.4 /
The task force largely ignored the value of PSA to identify men with asymptomatic locally advanced or metastatic prostate cancer. Early intervention in such men results in a major reduction in suffering, and extends their lives in many cases beyond 10 years. Prior to PSA, testing when men with metastatic disease mostly presented with symptomatic metastases including pathologic fractures, most lived 3 years or less despite hormonal therapy. While this cannot be captured in the sterile confines of randomized controlled studies, one cannot deny the need to help this group who will become much more prevalent in Hampton Roads if the USPSTF recommendation is adopted.
Ultimately, it is the view of the USPSTF that despite survival benefits of prostate cancer screening, the morbidity of treatment outweighs these advantages. It is our view that PSA-based prostate cancer screening offers a substantial survival benefit to our male patients, for whom prostate cancer is the second leading cause of cancer death (behind lung cancer). We acknowledge that there are potential harms that can stem from inappropriate screening execution and management of screen-detected prostate cancer. But it is paramount to distinguish between harms of screening and harms of treatment. The risks of harm from PSA testing and prostate biopsy are negligible. On the other hand, available treatments for prostate cancer may lead to significant problems with urinary control and erectile function. Our objective in the care of patients at risk for prostate cancer is to provide evidence-based counseling, thoughtful and rational screening, and individualized management of prostate cancer when it is detected. There is no “one-size fits all” treatment for prostate cancer. Accordingly, prostate cancer patients at Urology of Virginia can expect a broad management algorithm that includes active surveillance, robotic prostatectomy, external beam radiation, brachytherapy, cryotherapy, hormone therapy, and watchful waiting, so that management is individualized to the patient for optimizing benefits and minimizing harm.
We believe that all healthy men over age 40 should be offered the option of PSA testing for prostate cancer screening. We believe that high-risk groups of men should be especially encouraged to undergo PSA-based screening. These include African-American men, men with a strong family history of prostate cancer, and men exposed to Agent Orange in Vietnam. We believe that men with less than a 10 year life expectancy are unlikely to realize any benefits from prostate cancer screening, and should therefore not undergo routine PSA testing.
To quote directly from the preventive services task force recommendation statement, “the USPSTF recognizes the common use of PSA screening in practice today and understands that some men will continue to request screening and some physicians will continue to offer it. The decision to initiate or continue PSA screening should reflect an explicit understanding of the possible benefits and harms and respect the patient’s preferences.”
Information upon which to base recommendations and treatment decisions is critical. To ignore and discount PSA in the information age is counterproductive. Knowledge can lead to more informed and more appropriate decisions; ignorance does not. The physicians at Urology of Virginia look forward to further dialogue and progress with you in the care of our mutual patients.
On behalf of the physicians of Urology of Virginia, we thank you for your confidence in sending your patients to us. We appreciate your consideration of our concerns regarding PSA testing. Enclosed is a copy of an excellent article which summarizes this issue very nicely. Please feel free to contact us should you have any concerns or wish to discuss this in more detail.
If you have any new patient referrals, please call our New Patient Referral Line 757-452-3434.
The Physicians of Urology of Virginia
1. NEJM 360: 1310-1319, 2009
2. NEJM 366: 981-990, 2012
3. NEJM 364: 1708-1717, 2011
4. American Cancer Society, Cancer Facts & Figures 2012.