A Dangerous New Trend: More High-Risk Prostate Cancer Diagnoses

Ever since the U.S. Preventive Services Task Force (USPSTF) slapped a “D” rating on PSA screenings in 2012, countless physicians on the frontlines of prostate cancer treatment have been concerned about the life-threatening fallout. (You can read our earlier blog about the controversy here).

“We already know that PSA testing has declined significantly since the USPSTF published its recommendation,” says Richard Bevan-Thomas, M.D., medical director of USMD Prostate Cancer Center. “I’m not alone in my worry that this decline may usher in an increase in the number of men who will have high-grade prostate cancer, or cancer that has already spread beyond their prostate at their initial diagnosis.”

Dr. Bevan-Thomas’ concern is validated by new data that confirms an alarming trend. Results for a study that followed 12,000 men were recently presented at the 2016 Genitourinary Cancers Symposium in San Francisco. The study—the largest single-institution study on the subject—compared prostate biopsies performed in 2010 and 2011 (before the USPSTF ruling) with biopsies performed after the ruling in 2013, 2014 and 2015 (after the ruling).

Men in both sample sets were roughly the same age and had the same number of cores removed during their biopsies. Yet, researchers found the percentage of positive biopsies and the aggressiveness of the prostate cancer detected was greater in men who had biopsies after the USPSTF ruling.

The study revealed troubling news on another front, too: the diagnosis rate increased from 39.7 percent in 2010-2011 to 41.4 percent in 2013. Rates jumped again in 2015 to 45.4 percent.

The number of positive cores also rose from 31.4 percent in men who had biopsies before the USPSTF ruling, to 33.3 percent in 2015. In addition, the percentage of men diagnosed with Gleason 8 to 10 cancers rose from 15.5 percent in 2010-2011 to 24.5 percent in 2015.

Head researcher, Deepak A. Kapoor, M.D., an associate clinical professor of urology at Icahn School of Medicine at Mount Sinai in New York, finds the results disconcerting.

“They indicate that newly diagnosed cancers are presenting with increased tumor volume and grade, which may translate into an increase in prostate cancer-related mortality,” he says. “Although we can’t establish an absolute causal link to USPSTF from a single study, it is absolutely astonishing to see that the migration to more aggressive disease has happened so quickly after the recommendation.”

Dr. Bevan-Thomas and many other prostate cancer specialists believe it may be another five or 10 years before we truly know the full impact of the USPSTF’s actions.

“A continued decline in PSA testing could wipe out the positive gains that have been made with early detection. More men could die from prostate cancer,” he says.

Along with the “D” rating from the USPSTF (a panel of primary care physicians tasked with recommending which preventative health screenings should be covered under the Affordable Health Care Act), another development is causing controversy.

Medicare may soon penalize doctors who routinely order PSA blood tests by giving them demerits for being “over-spenders.” Docs who skip the test will be rewarded with a high “quality” rating and paid more.

“Prostate cancer continues to be a lethal disease that nearly 30,000 men die from every year,” Dr. Bevan-Thomas says. “We know that the decline in PSA testing is most serious in men 50 to 70 years old. Not long ago, I diagnosed a man in his early 50s. His PSA was 22 and his cancer had already spread beyond his prostate. He’s had surgery, radiation and hormone therapy—and now he’s probably going to die of prostate cancer in the very near future. That’s heartbreaking for me.

Had his cancer been diagnosed when his PSA was four, I would have had a much better chance of curing him.”

In the early stages of the prostate cancer, men don’t experience symptoms.

“Once they are symptomatic, the cancer is usually metastatic,” Dr. Bevan-Thomas explains. “At that point, we can find the cancer, but we can’t effectively treat it. The PSA test isn’t a perfect test, and it should always be done in conjunction with a digital rectal exam, but prostate cancer deaths have declined by 44 percent since the test was introduced in 1991.”

Despite the clear documented life-saving benefits of early detection, the assault on PSA testing is taking a very human toll.

“We’re seeing an uptick in the amount of high-grade cancer being diagnosed,” says Justin Lee, M.D., a surgeon with USMD Prostate Cancer Center. “Men need to be very proactive with their own health. You only have one life. Right now the PSA test is still the only guide we have for early detection.”

Paul Burek is glad he had a PSA test.

“My doctors kept saying you don't need a PSA test until 50. At 48 I said, ‘Run a PSA anyway to get a baseline.’ My score was 4.2. Biopsy was done and prostate cancer was found. I had a robotic prostatectomy at USMD on March 15, 2005 (5 days after turning 49). I've been PC-free with no detectable PSA since then. Glad I followed my gut,” he says.

Burek demonstrates why it’s important for men to talk with their physicians, and if necessary, a urologist about when and how often PSA screening is appropriate for them.

“We’re looking at trends, we’re not just looking at one PSA test,” Dr. Bevan-Thomas adds. “If someone had a PSA of 1.0 and all the sudden their PSA is 2.5, the first thing we’re going to do is validate that PSA with a repeat blood test. If your PSA is below 1.0, you are fine waiting three or four years before you have another test. But if you are high-risk because you have a family history of prostate cancer, are African American or have other risk factors, you should consider being tested on a more regular basis. What we’re really looking for is high-grade cancers. We don’t want someone to have their first PSA test and discover their level is 12.”

If you’d like to schedule a PSA test at USMD Prostate Cancer Center, please contact USMD Prostate Cancer Center online or at 1-888-PROSTATE (1-888-776-7828).

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