Prostate cancer: New PSA screening guidelines

Healthnetwork Foundation talks to a panel of experts on changes to PSA screening . . .

In May, the United States Preventive Services Task Force (USPSTF) announced in its final recommendation that healthy men should no longer get screened for prostate cancer with a prostate-specific antigen (PSA) test because a resulting diagnosis may do more harm than good. The USPSTF is an independent agency made up of experts in preventive or family medicine who serve a four-year term.

Men all over the country and their doctors are trying to understand why this recommendation was made. About 70% of American men over 50 have gotten a PSA blood test. Some are convinced that it’s a lifesaver. PSA is a protein produced by the prostate, and it can be detected with a simple blood test. It’s specific to the prostate but not prostate cancer. Prostate cancer doesn’t always present with symptoms in the early stages. We asked some foremost U.S. experts for their reaction.

David B. Agus, MD. Director, USC Westside Cancer Center, USC Keck School of Medicine: “PSA testing saves lives. Countries that do prostate screening have a much lower prostate cancer death rate than countries that don’t. That being said, we also over-treat prostate cancer in this country. The real argument should be about which prostate cancers need to be treated, not eliminating all screening. Many cancers can be followed on an active surveillance protocol, while others need to be treated. This is the art of medicine.”

Edward Schaeffer, MD, PhD. Co-director, Prostate Cancer Multi-Disciplinary Clinic, Johns Hopkins Medical Institutions: “I thought this ruling was a move in the wrong direction for patients. The new guidelines state that doctors do not need to discuss the test with their patients and do not need to obtain it. Today patients are very well educated about their health and want an open discussion about what tests/studies/labs their doctors are thinking about obtaining for them. I recommend a frank discussion between patients and their doctors about the blood test, their risk factors and their overall health. Generally I still believe in an initial PSA test beginning at age 50 (age 40 in men with family history or in men of African descent).”

Eric A. Klein, MD. Chairman, Glickman Urological and Kidney Institute, Cleveland Clinic: “It’s disappointing that a government agency would recommend taking the option for discussion about whether one should have a PSA out of the patient’s hands. The Task Force ignored a substantial amount of data that suggest there is value to PSA screening in reducing mortality in younger men and men with higher risk tumors. “I recommend a baseline PSA for men in their 40s. It helps identify who is at highest risk of developing cancer to be followed more closely — and who is at lower risk who then need not be screened until age 50. Generally yearly PSA is appropriate at age 50, but if it’s 2 or below it can be done every other year. Men with a PSA of <2 at age 60 are very unlikely to get aggressive prostate cancer and need not be screened after that.”

Ronald Rodriguez, MD, PhD. Associate professor of urology, Johns Hopkins Medical Institutions: “The panel for the PSA recommendation did not consist of any experts in prostate cancer, which is a serious defect. Yet despite true expertise, they issued a recommendation with profound potential adverse impact on the health of men in the U.S.

“I recommend that men continue with the screening process which has been in place for many years. All men should have a PSA test by the age of 50, with annual digital rectal exams and urinary symptoms assessment. Men with a family history should start screening at a younger age (e.g., 40 years old). If the PSA is very low at an early age in such men, then the next test can be deferred for up to five years, until they reach age 50.

“However, with the new recommendations, insurance reimbursement for such screening will not allow such tests to be ordered unless the patient is self-pay. Alternatively, men with other reasons for testing may potentially still get coverage (palpable nodule on rectal exam or severe urinary symptoms), though it remains to be seen precisely how insurance companies will respond to these issues.”

Susan Locke, MD, is Healthnetwork Foundation’s Medical Director.

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