Federal Panel Rejects Routine Prostate Cancer Screening

Michael LeFevre, MD, MSPH

The United States Preventive Services Task Force (USPSTF) has made a final recommendation against routine screening for prostate cancer in asymptomatic males. The influential federal panel concluded that screening healthy males through prostate-specific antigen (PSA) testing results in more harm than good.

“Prostate cancer is a serious health problem that affects thousands of men and their families,” said Michael LeFevre, MD, MSPH, co-chair of the USPSTF, in a statement released on Monday. “But before getting a PSA test, all men deserve to know what the science tells us about PSA screening: there is a very small potential benefit and significant potential harms.”

The USPSTF’s final decision upholds its October 2011 draft statement, which assigned PSA screening a “grade D” recommendation, meaning that the panel “recommends against routinely providing [the service] to asymptomatic patients.”

In the statement announcing its decision, the USPSTF noted that up to five in 1000 men will die within one month of prostate cancer surgery and between 10 and 70 men will have serious complications. Long-term adverse effects, such as urinary incontinence, erectile dysfunction, and bowel dysfunction, are closely linked to treatment. Likewise, the USPSTF cited that there is a high probability of overdiagnosis.

In an editorial, Otis W. Brawley, MD, MPH, Chief Medical Officer of the American Cancer Society, wrote that overdiagnosis might be a more serious problem than most people perceive, since many cases of prostate cancer may not progress after diagnosis and may not end up resulting in the death of the patient.

“Americans have been taught for decades to fear all cancer and that the best way to deal with cancer is to find it early and treat it aggressively,” Brawley said in the statement. “As a result, many have a blind faith in early detection of cancer and subsequent aggressive medical intervention whenever cancer is found. There is little appreciation of the harms that screening and medical interventions can cause.”

However, not all medical professionals are in favor of this recommendation. In a previous interview, Leonard G. Gomella, MD, Bernard W. Godwin Jr professor of prostate cancer and chairman of the Department of Urology at Thomas Jefferson University Hospital in Philadelphia, Pennsylvania, said he remains in favor of the testing because a better option does not yet exist and there is evidence that supports its effectiveness.

For example, in a meeting of the North Central Section of the American Urological Association in California in October 2011, researchers at the Mayo Clinic in Rochester, Minnesota, presented a study that suggested that PSA screening was valuable. The study found that men in their 40s with a baseline PSA at or above 4.0 ng/mL were much more likely to undergo a biopsy and be diagnosed with low-level prostate cancer.

“[The USPSTF] has completely trashed PSA testing,” Gomella said. “Until we have a new test other than PSA, to say it shouldn’t be done is not fair.”

After the final recommendation was issued, the Obama administration said that Medicare would continue to pay for the PSA blood test. There was concern that Medicare would follow the lead of the USPSTF and no longer cover the test. This could have potentially had a domino effect across many health insurance plans, since many follow Medicare’s lead in determining which tests to cover.