Politics and Science Intersect in PSA Screening

Leonard G. Gomella, MD

The Bernard W. Godwin Jr. Professor of Prostate Cancer Chairman, Department of Urology Director, Clinical Affairs Kimmel Cancer Center Thomas Jefferson University Philadelphia, PA

In October 2011, the US Preventive Services Task Force (USPSTF) issued a draft statement recommending against prostate cancer screening in any asymptomatic male. At the IPCC, Leonard G. Gomella, MD, professor and chairman of the Department of Urology, and director of Clinical Affairs at the Jefferson Kimmel Cancer Center, Thomas Jefferson University Hospital in Philadelphia, Pennsylvania, discussed the public policy and medical implications of the USPSTF’s recommendation.

In its statement, the USPSTF concluded that the benefits of prostate-specific antigen (PSA) screening do not outweigh its risks. “The vast majority of men who are treated do not have prostate cancer death prevented or lives extended from that treatment, but are subjected to significant harms,” the panel concluded.

The USPSTF assigned PSA screening a “D” rating. This is a problem, according to Gomella, because the 2010 Affordable Care Act (ACA) stipulates that health plans need only to fully reimburse services that receive either an “A” or “B” rating from the USPSTF.

“If the D rating sticks, Medicare would no longer be required to cover PSA screening,” said Gomella. He added that this would drastically reduce the use of PSA because, “As late as 2008, over three-quarters of male Medicare beneficiaries were being screened for prostate cancer.”

This reduction in screening would have a detrimental impact on prostate cancer treatment and mortality rates, according to Gomella. He said that not screening asymptomatic men is a “contrarian concept because once a man becomes symptomatic for prostate cancer, the ability to offer him potential curative therapies are limited.”

Gomella is confounded by the USPSTF’s universal dismissal of prostate cancer screening, even in high-risk males, such as African Americans or those with a familial history of the disease.

While Gomella said that the PSA test is imperfect, he strongly supports its continued use. “Don’t abandon something that works because there’s nothing better out there right now.”

PSA testing has led to earlier diagnosis, a 70% reduction in metastatic disease at presentation, and, since its introduction, an annual decline in US prostate cancer mortality rates of 4%, according to Gomella. He added that the number of patients that need to be screened to prevent one death is “basically identical with prostate and breast cancer.”

Gomella admitted that there are negatives with the PSA test, including its inability to diagnose the aggressiveness of the tumor. “We know that the PSA test cannot tell the difference between a prostate cancer that will and will not affect a man during his natural lifetime,” he said. This shortcoming can lead to overtreatment of insignificant cancers, which increases healthcare costs and can unnecessarily reduce a patient’s quality of life.

However, Gomella considers PSA screening itself and any subsequent overtreatment to be two separate issues. The actual PSA blood test is essentially risk-free, he said. The complications arise from the ensuing biopsies and treatments that may not be necessary. Gomella maintains that the USPSTF failed to account for this distinction when making its recommendation. “It’s really not a statement about screening, and that’s where they did a great disservice,” said Gomella.

Gomella also suggested that the data reviewed by the USPSTF were limited and outdated. He additionally questioned the panel’s decision to weigh equally the results of the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial and the European Randomized Study of Screening for Prostate Cancer (ERSPC), given the PLCO’s higher degree of contamination. The ERSPC demonstrated that PSA screening decreased prostate cancer mortality rates; however, a clinical benefit for PSA testing was not found in the PLCO trial.

It is still unknown when the USPSTF will release the official version of its PSA draft recommendation. In the meantime, concerns about the policy could be rendered moot if the Supreme Court declares the ACA unconstitutional in its current review of the bill.

If the ACA is upheld, state legislatures could get involved in challenging the USPSTF’s anti- PSA recommendation. New Jersey recently became the first state to enact legislation officially opposing the policy.