A government panel recommended on Monday against screening healthy men for prostate cancer with the PSA blood test, concluding that harm from the widely used test outweighed its benefits in all age groups.
The US Preventive Services Task Force determined that based on evidence from two large randomized trials, the lifesaving benefits of screening were “at best very small” and were offset by overdiagnosis and overtreatment of non-lethal cancers.
But whether doctors and patients will follow the panel’s advice is unclear—groups representing cancer doctors and patients objected to the recommendation, and a top official of the American Cancer Society said physicians by and large do a poor job of discussing the PSA tests’ benefits and risks with patients.
The panel of independent primary care and public health specialists had said in 2008 that PSA testing was not advisable for men 75 and older but that evidence was inconclusive on its merits for younger men. That recommendation hasn’t led to a drop in PSA screening among older men, according to research published last month in the Journal of the American Medical Association.
Now the panel has extended its recommendation against PSA screening to men of all ages.“Our most optimistic estimate is that 1 out of 1,000 men screened will avoid dying from prostate cancer” because of early detection via the PSA test, said Dr. Michael LeFevre, co-vice chair of the task force. “We’re not saying it’s zero. We’re leaving the window open for at least a small benefit.”
That benefit, he added, must be stacked against a near doubling in the likelihood of being diagnosed with prostate cancer and having side effects from radiation or surgical treatments. He said 40 out of 1,000 men screened are left with permanent disabilities from their treatment such as urinary incontinence or impotence, and almost all of them have slow-growing cancers that wouldn’t have been fatal.
But many of those who treat prostate cancer—or who have had it themselves—argue that comparing a life saved with treatment side effects, however disabling, is like comparing apples with oranges.
“It’s hard to understand where they’re coming from,” said Dr. Anthony D’Amico, chief of genitourinary radiation oncology at Brigham and Women’s Hospital, in an interview. In an editorial he co-authored in the Annals of Internal Medicine journal, where the new recommendations were published, D’Amico argued that the task force relied too heavily on data from a flawed study and failed to consider making separate recommendations for men in high-risk groups, such as those with a family history of prostate cancer and African Americans, who have a two to three times greater risk of dying of the cancer than white men.
The task force, which is comprised of 16 primary care physicians and public health experts with no financial interests in tests or treatments, issues screening and other preventive health recommendations that tend to be more conservative than those of medical societies—composed mostly of specialists who treat diseases detected through screening—or patient advocacy groups.
In 2009, its expert panel came under a barrage of fire when it veered against nearly every American medical organization and stopped recommending routine mammograms for women in their 40s; the recommendation advised women to speak to their doctors about the risks and benefits before reaching an individual decision.
The political fallout from that surprise downgrade led to specific language in the federal health care legislation last year mandating free coverage of mammograms in women age 40 and older and also led Congress to demand more transparency in the task force’s decision-making. For PSA testing, the panel first issued draft recommendations last October and invited public comments, though the final language didn’t change much from the draft. (PSA testing isn’t one of the free preventive services required to be offered under the federal health law.)
The American Cancer Society has no plans to alter its own advice on PSA screening—advising men to discuss the benefits and risks with their doctor before making a decision—but its chief medical officer, Dr. Otis Brawley, said he agreed with the task force’s new recommendations.
“I think their process is exactly where it ought to be,” Brawley said. “It removes those people who have emotional, ideological, or financial conflicts of interest” from being on the panel. Doctors and hospitals, which get paid for performing follow-up biopsies and treatments that result from screening, have a strong interest in seeing as many men screened with PSA as possible, he added.
In Massachusetts, several hospitals offered free PSA tests and digital rectal exams during “prostate cancer awareness week” screening programs in September. A charity called Zero sends vans throughout the country to offer free screening and boasts on its website, “110,000 men tested.” The American Urological Association, a medical society representing urologists who treat prostate cancer, is listed as a partner on Zero’s website and provides educational support.
Jamie Bearse, chief operating officer of Zero, said each van has two doctors who provide men interested in screening with educational materials outlining the full risks and benefits of prostate cancer screening; men with elevated PSA levels are then referred for follow-up exams to whichever hospital Zero partners with in a particular town.
Former New England Patriots player Mike Haynes, a paid spokesperson for the urological association, said in an interview that he was diagnosed with prostate cancer in 2008, at age 55, after getting a free screening PSA test at an NFL event for retired players, sponsored by the urological association. He said he wasn’t told about any of the risks of the tests such as false positive results, unnecessary biopsies, and overtreatment of slow-growing cancers. His elevated PSA and subsequent biopsy revealed a stage 1, slow-growing cancer, and he said, “one of my options was watchful waiting, but my immediate reaction was let’s get it out of my system.”
He considers himself lucky, however, in that the only side effect he had from his surgery was a few months of urinary incontinence that has since resolved.
Urological association president Dr. Sushil Lacy said that PSA screening approaches have evolved since Haynes was screened and that men are now better educated during these free campaigns, but Brawley said it’s nearly impossible to have a real discussion about the risks and benefits of PSA outside of a physician-patient relationship—and all too often, even within one.
Haynes said his primary care physician had been performing PSA screening on him for years without even telling him.
“I think the task force came down harsh with their new recommendation,” said Brawley, “because we have definite evidence that informed decision-making isn’t happening.”