AUA disagrees with USPSTF prostate cancer screening recommendation

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Urologists from the American Urological Association, otherwise known as the AUA, say they do not agree with the US Preventive Services Task Force recommendation against screening for prostate cancer. The task force has argued and continues to argue that there is no good evidence to support screening for prostate cancer using the PSA (prostate-specific antigen) blood test.

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The chair of public policy for the AUA, David Penson, MD, says this has resulted in a decrease in screening and possibly an increase in high-risk prostate cancers. Dr. Penson said: "I suspect we'll see a return to days when men present with prostate cancer and it's already spread all over their body.”

What’s concerning is that the Affordable Care Act requires Medicare to cover services that receive an A or B rating from the task force. When it comes to ratings, prostate cancer screening gets a D. This rating was first issued in 2011. A grade D means that there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. It also means that people with Medicare may have to pay a co-pay to have their PSA tested. It could also potentially mean that Medicare may deny paying for the PSA test completely.

This past March, the AUA, the American Association of Clinical Urologists, and the Large Urology Group Practice Association, issued a statement in support of the US Preventive Services Task Force Transparency and Accountability Act of 2015. The bill insists on major changes among the process by which the task force makes formal recommendations about preventive care services. According to Dr. Penson, "The AUA believes first and foremost that the process is inherently flawed."

What’s wrong with USPSTF recommendation against prostate cancer screening

  • It focuses on complications of treatment (incontinence and erectile dysfunction) but not on the value of screening and the amount it has saved the healthcare system
  • It discusses population screening, but ignores African Americans, the effect of family history, and morbidity associated with prostate cancer
  • No one on the task force has actually treated patients with prostate cancer
    • Task force is made up of 16 volunteer members who are experts in prevention, evidence-based medicine, and primary care
    • Their fields of practice and expertise include behavioral health, family medicine, geriatrics, internal medicine, pediatrics, obstetrics and gynecology, and nursing
  • Prostate cancer mortality was on the decline before the task force issued its recommendation
  • Task force failed to take into account evolving trends in the thinking of urologists regarding the PSA testing and prostate cancer treatment
  • Recommendation has also affected policy - some commercial payers are denying coverage for PSA testing
    • Will affect patient outcomes in the long run
  • Decisions are being made without proper input from the specialists who treat these diseases
  • Prostate cancer mortality was on the decline before the task force issued its recommendation
  • Since PSA testing, we have seen a 40% reduction in prostate cancer mortality in the United States

Prostate cancer screening pros v. cons

Pros:

  • PSA screening may help you detect prostate cancer early.
  • Cancer is easier to treat and is more likely to be cured if it's diagnosed in the early stages of the disease
  • PSA testing can be done with a simple, widely available blood test. 
  • For some men, knowing is better than not knowing. Having the test can provide you with a certain amount of reassurance — either that you probably don't have prostate cancer or that you do have it and can now have it treated.
  • The number of deaths from prostate cancer has gone down since PSA testing became available.

Cons:

  • Some prostate cancers are slow growing and never spread beyond the prostate gland.
  • Not all prostate cancers need treatment. Treatment for prostate cancer may have risks and side effects, including urinary incontinence, erectile dysfunction or bowel dysfunction.
  • PSA tests aren't foolproof. It's possible for your PSA levels to be elevated when cancer isn't present, and to not be elevated when cancer is present.
  • A diagnosis of prostate cancer can provoke anxiety and confusion. Concern that the cancer may not be life-threatening can make decision making complicated.
  • It's not yet clear whether the decrease in deaths from prostate cancer is due to early detection and treatment based on PSA testing or due to other factors.

Arguments for & against PSA screening

Arguments for screening:

  • Results from a large European study of prostate cancer screening found that men who had PSA testing had a 20 percent lower chance of dying from prostate cancer after 13 years, compared to men who did not have prostate cancer screening
  • A substantial number of men die from prostate cancer every year and many more suffer from the complications of advanced disease.
  • For men with an aggressive prostate cancer, the best chance for curing it is by finding it at an early stage and then treating it with surgery or radiation. Studies have shown that men who have prostate cancer detected by PSA screening tend to have earlier-stage cancer than men who have a cancer detected by other means.
  • The five-year survival for men who have prostate cancer confined to the prostate gland (early stage) is nearly 100 percent; this drops to 30 percent for men whose cancer has spread to other areas of the body. However, many early-stage cancers are not aggressive, and the five-year survival will be nearly 100 percent even without any treatment.
  • The available screening tests are not perfect, but they are easy to perform and have fair accuracy.

Arguments against screening:

  • Even though the European study found a benefit of prostate cancer screening, only about 1 man in every 1000 benefited from PSA testing after 13 years.
  • Furthermore, 75 percent of men with an abnormal PSA who had a prostate biopsy did not have prostate cancer.
  • A large American study did not find that prostate cancer screening reduced the chance of dying from prostate cancer

What people should know about PSA screening

  • Screening doesn’t lower your risk of having prostate cancer; it increases the chance you’ll find out you have it.
  • PSA testing can detect early-stage cancers that a DRE would miss.
  • A “normal” PSA level of 4.0 ng/mL or below doesn’t guarantee that you are cancer-free; in about 15% of men with a PSA below 4.0 ng/mL, a biopsy will reveal prostate cancer.
  • A high PSA level may prompt you to seek treatment, resulting in possible urinary and sexual side effects.
  • Conditions other than cancer (BPH and prostatitis) can elevate your PSA level.