PSA Screening Decision is a Balancing Act

After an extensive review of the medical literature concerning prostate cancer screening, the U.S. Preventive Services Task Force (USPSTF) recently stated that the number of lives saved is “at most, very small,” and that the proven risk for harm outweighs any potential benefit.

The USPSTF recommended against routine screening but allows for selective screening within the doctor-patient relationship after the patient is informed of the known risks of screening and treatment, and the potential benefits.

The fact that prostate-specific antigen (PSA) screening would be questioned is surprising to many. Truth be told, over the past few years, a number of respected medical organizations have made consistent statements indicating that there are legitimate questions about the efficacy of prostate cancer screening and treatment.

The problem: There is clearly a large group of men with prostate cancer who have a disease that will never harm them. There is also a group of men with prostate cancer that cannot be cured, no matter when it is found. The question then becomes, “What proportion, who are diagnosed through screening, can be cured?” We do not have a good test to determine that.

Some clinical trials suggest screening and its resultant treatment is net beneficial to the population screened. Some suggest it is not.

No study suggests a large benefit. The most positive study suggests screening may save the lives of, at most, 5 percent of men who receive a diagnosis. All studies demonstrate that screening leads to some unnecessary treatment that is associated with harm. Outcomes studies suggest that some prostate treatments cause death in a small percentage of patients treated. Other potential harm from treatment includes infection, urinary incontinence, bowel problems and impotence. Unnecessary hormone therapy can cause diabetes and cardiovascular disease.

A number of respected medical organizations have made consistent statements indicating that there are legitimate questions about the efficacy of prostate cancer screening and treatment.

For more than a decade, the American Cancer Society has stated that the evidence supporting PSA screening is inconsistent. Our current recommendation: “Asymptomatic men who have at least a 10-year life expectancy should have an opportunity to make an informed decision with their healthcare provider about whether to be screened for prostate cancer after receiving information about the uncertainties, risks and potential benefits associated with prostate cancer screening.”

Consider similar statements by these well-respected medical groups:

> The National Comprehensive Cancer Network: “There are advantages and disadvantages to having a PSA test, and there is no ‘right’ answer about PSA testing for everyone. Each man should make an informed decision about whether the PSA test is right for him.”

> The European Urology Association: “Men should obtain information on the risks and benefits of screening and make an individual risk assessment.”

> The American Urological Association’s Prostate-Specific Antigen Best Practice Statement: “Given the uncertainty that PSA testing results in more benefit than harm, a thoughtful and broad approach to PSA is critical. Patients need to be informed of the risks and benefits of testing before it is undertaken. The risks of overdetection and overtreatment should be included in this discussion.”

> The American Society of Clinical Oncology recommends physicians discuss with patients who have a life expectancy of greater than 10 years whether PSA testing for prostate cancer screening is appropriate for them.

For more than 20 years, I have counseled patients and physicians to be cautious about screening. Given that the results of scientific study do not fully support screening, I believe men should be informed of what is known and what is not known about the procedure and make their own decision. 

Otis W. Brawley, MD, is the chief medical and scientific officer of the American Cancer Society.