PSA Screenings Decline Following New Recommendations

The Journal of Urology reports that prostate-specific antigen (PSA) testing has declined in the United States following a 2013 recommendation by the US Preventive Services Task Force (USPSTF)—a group of primary care physicians charged with developing recommendations about which preventative health screenings should be covered under the Affordable Health Care Act.

News about the decline coincides with new data just released by the European Randomized Study of Screening for Prostate Cancer (ERSPC) that shows men 50 to 74 years old who undergo PSA screening have a significant advantage in surviving prostate cancer compared to men who aren’t screened. The study, which began 20 years ago, is a randomized study that follows more than 180,000 men—only half of whom have regular PSA tests—and offers updates every two years.

The newest stats reveal “a prostate cancer mortality reduction of 20 percent in men who started PSA screening after age 60, while men who started screening before age 60 had a reduction of 50 percent.” Experts are calling the update the most robust data yet supporting the effectiveness of PSA-based early detection in the reduction of prostate cancer metastases and mortality.

Richard Bevan-Thomas, M.D., medical director of USMD Prostate Cancer Center, believes the new ERSPC results highlight why a decline in PSA testing is troubling news.

“Prostate cancer continues to be a lethal disease that nearly 30,000 men die from every year. In the early stages of the disease, men don’t experience symptoms. Once they are symptomatic, the cancer is usually metastatic. 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 it was introduced in 1991,” he says.

Despite its direct link to the drop in prostate cancer deaths, USPSTF gave the PSA test a “D” rating in 2012 on two studies—one in the United States and one in Europe. Both studies concluded that too many men had to be treated in order to prevent one death. In the U.S. study, 10 men had to be treated to prevent one death, while in the European study 37 men were treated to prevent one death. The USPSTF also claimed PSA testing causes anxiety and is associated with more harm than benefit.

“I think people are confusing PSA testing with the risks and side affects associated with biopsy and prostate cancer treatment. They are very different. The PSA test is a simple blood test—there isn’t any risk associated with it,” Dr. Bevan-Thomas says.

Despite the USPSTF’s recommendation, the PSA test remains one of the best tools we have for early detection of prostate cancer. Knowing your PSA level will help you and your doctor decide if you should have a biopsy. Having your prostate cells examined under a microscope is the only way to determine if cancer is present. An initial PSA test provides men and their doctors with a baseline that can be monitored over time.

“We’re looking at trends, we’re not just looking at one PSA test,” Dr. Bevan-Thomas says.
“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 may want to be 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 their level is 12.”

Levels measuring less than 2.5 are considered within the normal range, but it should be noted that men with a PSA level between 2.5 and 4.0, have a 21 to 23 percent risk for prostate cancer. For men with a PSA level above 4.0, the risk is roughly 27 to 29 percent. “The higher the PSA, the higher the risk that the man could be harboring a focus of cancer,” Dr. Bevan-Thomas says. “Our goal with PSA screening is to find prostate cancer early enough, so we can cure a majority of these patients. The higher that PSA goes, the less chance that we can actually cure those patients.”

If PSA testing continues to decline, men may not have important information they need to make educated health decisions. Dr. Bevan-Thomas is concerned that the continued decline in PSA testing could wipe out the positive gains that have been made with early detection and bring an increase in the number of death caused by prostate cancer.

“We’re at a critical time. Baby boomers are growing older, and I’m seeing more men with PSA levels of 100 than I have in quite some time. If I see a patient who is complaining of back pain and he has a PSA of 150, it’s likely the cancer is already in his bones. We cannot cure patients with advanced disease. For men in their 40s, 50s and 60s who have significant lifespan ahead of them, the PSA is still a good screening test. We just need to use it appropriately and validate results when we see an elevated PSA level.”

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