May 24, 2012
The American Urological Association (AUA) released the following statement in response to the U.S. Preventive Services Task Force (USPSTF) recommendations on the use of the prostate-specific antigen (PSA) test. The statement is attributed to AUA President Sushil S. Lacy, MD:
The American Urological Association (AUA) is outraged at the USPSTF's failure to amend its recommendations on prostate cancer testing to more adequately reflect the benefits of the prostate-specific antigen (PSA) test in the diagnosis of prostate cancer. It is inappropriate and irresponsible to issue a blanket statement against PSA testing, particularly for at-risk populations, such as African American men. Men who are in good health and have more than a 10-15 year life expectancy should have the choice to be tested and not discouraged from doing so.
There is strong evidence that PSA testing saves lives. The randomized trials used by the USPSTF do, in fact, show a benefit to patients. The PLCO Trial, imperfect by the pre-screening contamination of the control arm, nonetheless showed that, in a group of young men with no comorbidities, there was a significant reduction of prostate cancer death rates after a median follow-up of seven years (JCO 2011;29:355-361). Additionally, the Göteborg Trial also showed a substantial 44 percent relative risk reduction in prostate cancer mortality occurring in men 50-64 years of age after a median of 14 years. Importantly, the risk reduction occurred in a setting where many of the patients were not aggressively treated for prostate cancer, indicating that the harms of PSA-based screening can, in fact, be minimized by good clinical practice (Lancet Oncol 2010;11:725-732). Furthermore, we have seen a 40 percent reduction in prostate cancer-specific mortality in the United States over the most recent 20 years of PSA-based screening. This has occurred without substantial change in how men with prostate cancer were treated (primarily with surgery and radiation therapy). Models have suggested that more than 50 percent of this reduction is due to early detection (Cancer Cases Control 2008;19:175-181). Additionally, updated data from the European Randomized Study for the Screening of Prostate Cancer (ERSPC) has demonstrated that there is a 21 percent risk reduction in prostate cancer related death associated with screening (up to 29 percent after accounting for non-compliance). The number of cancers that would need to be detected to prevent one death has now dropped to 37.
Rather than instruct primary care physicians to discourage men from having a PSA test, the Task Force should instead focus on how best to educate primary care physicians regarding targeted screening and how to counsel patients about their prostate cancer risk. The PSA test has allowed us to move beyond a time when men presented with high-grade, metastatic disease for which there were little or no treatment options other than palliative care. In its earliest stages, most prostate cancers cause no symptoms; to say that only men with symptoms of prostate cancer should be tested will potentially result in a return to such a time.
Disparaging the PSA test when newer tests and diagnostics are not yet widely available does a great disservice to American men.
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