Save PSA Testing and Make a Public Comment Soon, Says AUA
November 7, 2011 — Americans are being urged by a spokesperson from a major professional organization to show support for prostate-specific antigen (PSA)-based screening for prostate cancer in men.
In a newspaper editorial, J. Brantley Thrasher, MD, a spokesperson for the American Urological Association (AUA), has encouraged the public to protest the US Preventive Services Task Force (USPSTF) draft recommendation against screening healthy men with the PSA test.
In draft guidelines published October 7, the USPSTF recommended against using the PSA test in men who "do not have symptoms that are highly suspicious for prostate cancer, regardless of age, race, or family history." In other words, the USPSTF is recommending against the routine use of the test in healthy men.
This conclusion "is flawed, dangerous, and catastrophic for men," writes Dr. Thrasher in the Kansas City Star newspaper editorial. Dr. Thrasher is the William L. Valk professor and chair of urology at the University of Kansas School of Medicine in Kansas City.
Dr. Thrasher encourages interested citizens and physicians to go to the USPSTF Web page and submit comments on the draft recommendation. The last day for public comment is November 8.
In defense of routine testing, Dr. Thrasher states, among other things, that "in almost every country presently performing PSA screening, mortality rates from prostate cancer have declined."
He also states the AUA’s basic position on PSA testing: "The American Urological Association currently supports the use of PSA and believes when used and interpreted appropriately, the PSA test provides important information in the diagnosis…of prostate cancer patients."
A rallying cry from the AUA is an understandable reaction to the USPSTF draft recommendation. However, the organization is somewhat alone in their campaign, compared with the concerted outcry that followed the controversial mammography screening report from same group.
The USPSTF recommendation in 2009 against routine mammography screening for breast cancer in women younger than 50 years provoked outrage from some breast cancer experts, patient advocates, and professional societies, and even included accusations of healthcare "rationing."
A review of press statements on the Web sites of a number of major medical organizations with a potential interest in prostate cancer screening found no official statements. Organizations with no posted official response include the American Cancer Society, the American Society of Clinical Oncology, the College of American Pathologists, and the American Academy of Family Physicians.
The AUA has been joined by such groups as the Prostate Cancer Foundation and ZERO–The Project to End Prostate Cancer in making public statements in support of the ongoing practice of routine PSA screening.
Prostate Experts Defend PSA Testing
Many individual prostate cancer experts in the United States have condemned the draft recommendation by the USPSTF.
The draft form of the recommendation was published online in the Annals of Internal Medicine. In it, the USPSTF extended its recommendation against PSA screening to all men (it had previously specified men older than 75 years), after determining that the evidence of benefit in terms of prostate cancer mortality is outweighed by evidence of potential harm. The recommendation has a "D" rating, which signifies that "there is moderate or high certainty that the service has no benefit or that the harms outweigh the benefits."
Medscape Medical News found an array of opinions about the worth of PSA testing.
"It’s true that long-term studies have found that PSA screening and early diagnosis of prostate cancer does not save lives," said Marc Garnick, MD, a clinical professor of medicine at Harvard Medical School with an oncology practice at Beth Israel Deaconess Medical Center in Boston, Massachusetts.
Despite the tenor of these remarks, Dr. Garnick does not support the USPSTF recommendation. "It’s also important to remember that certain men — such as African American men and those with a family history of prostate cancer — are at higher risk of developing prostate cancer than others, and may want to undergo regular PSA tests." His comments appeared on a Harvard health blog.
"This is the wrong message at this point in time," said Philip Kantoff, MD, director of Dana-Farber’s Lank Center for Genitourinary Oncology in Boston.
"The whole issue of PSA-based screening is complex. It involves multiple steps and multiple decision points. The blanket statement saying that PSA-based screening is of no value is the wrong message right now," he noted in a statement.
"There is no question that we need to be more careful with whom we screen, and we need to recognize that not every man needs to be screened," Dr. Kantoff explained. He acknowledged that the PSA test has issues with specificity and sensitivity, but he concludes that it is a useful screening tool when it is used appropriately.
