PSA screening for prostate cancer certainly has its limitations but should not be abandoned. Widespread use of PSA screening for prostate cancer began in the early 1990’s. From 1992-2001, there was a 47% decrease in prostate cancer mortality in the US (according the SEER data). Despite this fact, the US Preventative Services Task Force (USPSTF) came out in 2013 with strong statements condemning PSA test. The Task Force claimed that the ‘harms’ of PSA testing outweigh the benefits. This has left many patients and physicians confused about the value of PSA testing.

To be clear, the Task Force is not suggesting the actual blood test itself is dangerous or harmful. Their criticism is that an elevated PSA blood test leads to further testing and treatment, and that treatment that may lead to unnecessary harm.

The USPSTF recommendations were based on the outcome of part of the US-based PLCO (Prostate Lung Colorectal Ovarian) cancer trial. In this study, men were randomized to PSA screening vs. no screening and followed for overall and prostate cancer-specific survival. The study showed no survival benefit in the men with PSA screening. This was the main basis for the criticism of PSA screening.

Unfortunately, this study was significantly flawed by contamination bias. Over 40% of the men enrolled in the study had already had PSA screening prior to enrollment in the study! In essence, this excluded men who may have had significant cancers, whereas men who were unlikely to have lethal cancers were enrolled.

In the control group – i.e. men who were NOT supposed to have screening – over half of the men elected to have PSA screening anyway! Again, this contamination bias greatly altered the outcome of this study and makes it impossible to draw any conclusions about the results of the study or the value or efficacy of PSA screening.

Another trial on PSA screening based in Europe was a much better study. This European study demonstrated a significant survival benefit in men who underwent routine PSA screening. Similar to the PLCO study, men in the European Trial of Prostate Cancer Screening were randomized to PSA screening vs. no screening and followed for overall and prostate cancer-specific survival. This study was very different than the PLCO study because most of the men had never been exposed to any PSA testing previously, so contamination was not an issue.

With 13-year follow-up data published recently, this trial demonstrated a dramatic 27% reduction in prostate cancer mortality with PSA screening. This benefit was most notable specifically in the men ages 55-69. These results are the basis for the American Urological Association (AUA) guidelines of routine PSA screening in men ages 55-69.

Based on the flawed PLCO study, the USPSTF gave PSA screening a Grade D recommendation. This unfortunate designation suggests that routine PSA screening should not be performed. This is suggesting that men should, in essence, stick their heads in the sand. This is WRONG.

PSA screening for prostate cancer is not perfect but let’s not throw the baby away with the bath water. The issue with prostate cancer detection SHOULD NOT be whether or not men should be screened. The issue SHOULD be how do we manage the cancers we find?

For many years, clinically insignificant prostate cancers that do not pose a serious threat of spreading or leading to mortality have been treated very aggressively with surgery or radiation therapy. These treatments provide highly effective cancer control, but can also cause fairly significant life-altering morbidity such as incontinence, erectile dysfunction, pain, and radiation effects on surrounding organs. Many of these men with clinically insignificant cancers would have had actually had similar long-term survival with active surveillance.

Rather than abandoning PSA testing, we should focus on better risk stratification. Instead of sticking our heads in the sand, a better approach is (A) find prostate cancer, (B) determine how aggressive the cancer is and finally (C) manage it appropriately. Some cancers can be managed with active surveillance. Some need aggressive treatment such as surgery or radiation therapy. Some are candidates for HIFU or focal therapy. The key is to recognize that every cancer is different and needs to be handled accordingly. For more information, or call 941.329.7888

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