At any rate, what's this got to do with anything? Well, this week might mark the beginning of the end for another metaphorically trusted friend: the PSA. For many years, men have been screened for prostate cancer, but based on new widely publicized guidelines this may end.
The U.S. Preventive Services Task Force (USPSTF) has just ratified it's draft recommendations . That's the "D" grade (more harm than good) with respect to PSA screening in men as a preventive strategy for prostate cancer (Moyer et al, Annals May 21 issue). A recommendation against PSA-based screening for men of any age. This despite the fact that prostate cancer is the second commonest cause of death (after lung cancer) among men in the United States. In 2010, an estimated 217 730 men were diagnosed with the disease and 32 050 died from it.
By giving PSA a thumbs down it is quite possible - perhaps probable and inevitable - that Medicare and many third-party insurers will stop paying for routine PSA screening. Many men will be denied the option of having a PSA measured.
The current issue of the Annals of Internal Medicine has a series of articles that I would highly recommend. As someone who initially had my doubts about PSA screening, I now favor it after having read the primary literature, talked with urologists, and thought about this after managing a couple of patients who had cancers detected after elevated PSA's. I favor allowing the patient-doctor discussion over risks and benefits to prevail in the decision to screen or not to screen. As well, I very much agree with the commentary by Catalona and colleagues, which points out flaws in the evidence on which the USPSTF guideline is based.
Aside from pointing out that the USPTSF did not include urologists or cancer specialists as a part of their panel, Catalona et al also point to flaws in the design and results of the US PLCO study and the [European] ERSPC study, especially the US PLCO study. These are the 2 major studies. They point to contamination (by non-protocol checking of PSAs) in the unscreened group as a key problem. They also point out that the follow-up in these studies is not sufficiently long - a median follow-up of about 10 years - not long enough, they argue, for evaluating outcomes in a cancer that may grow slowly but have devastating effects in its advanced form.
Frankly, I found the arguments by Catalona et al quite persuasive. The counter view - by Otis Brawley - focuses on the perils of mass screening and over-diagnosis but really doesn't address whether the arguments made by the USPTSF are on solid ground scientifically, despite I should add, his suggestion that "We need to practice medicine on the basis of evidence and not on the basis of faith." Dr. Brawley suggests that "physicians have a special obligation to ensure that the patient understands the proven risks and the unproven benefits of PSA-based screening." Is Dr. Brawley being naive? Does he really believe that insurers will give doctors this luxury? Rather, it is more likely that insurers will stop paying for PSA's.
Bottom-line: I plan to ask my general internist to continue to check my PSA. My views may not be as extreme as some, but I'd rather struggle with figuring out how to deal with an increased PSA level as an individualized decision.
All I know is that my own father had an elevated PSA, and they found a small malignancy. He was one of those who didn't want any cancer inside of him, so he had radiation therapy. The result was disappearance of the tumor, but his urinary tract was damaged by the radiation. As a result, he had one UTI after another for years and seemed to be on a never ending cycle of antibiotics. He died not of cancer but from septicemia. He and his doctor ended up making the wrong individualized decision.
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