PSA testing still has its place
As a urologist practicing in Portland, I am gravely concerned by the new recommendations of the U.S. Preventive Services Task Force (USPSTF) against prostate specific antigen (PSA) testing. These recommendations do a great disservice to men around the country, particularly those with a higher risk of the disease (i.e., African American men, those with a family history of the disease, those who are underinsured and those who live in rural areas with limited healthcare access).
The decision to be tested for prostate cancer is an individual decision that men should discuss with their physicians; there is no single standard that applies to all men - nor should there be. No one can dispute that the PSA test has limitations, but when used and interpreted appropriately, the test provides valuable information in the diagnosis, pre-treatment staging, risk assessment and monitoring of prostate cancer patients.
The American Urological Association recommends that the best decisions regarding prostate cancer testing come from individualized discussions between a man and his urologist. It would be barbaric to universally dismiss the PSA test before a suitable alternative to prostate cancer diagnosis is available. There are many men in this community who would tell you that a PSA test saved their life.
I have practiced urology for 29 years at Kaiser Permanente in Portland following completion of a 5 year urology residency at OHSU. We have a department of 17 urologists who care for nearly a half million members. We have diagnosed and treated thousands of men with prostate cancer. We unanimously disagree with the USPTF recommendation. We feel that it is a distorted misrepresentation of available data. The recommendation is biased, wrong and dangerous.
Among the several problems with the USPTF recommendation are 1) It talks about not screening 'asymptomatic men.' The problem is that localized prostate cancer (the only type of prostate cancer that can be cured with surgery or other modes) is usually NOT associated with symptoms. Prostate cancer does not become 'symptomatic' until it's too late. That is, it has already spread beyond the confines of the prostate.
It will then cause obstruction of the kidneys or bladder, pain, or spread to bones or lymph nodes.
2) The claims of over diagnosis and over treatment are over exaggerated.
3) The three studies upon which the USPTF recommendation are based (the PLCO, Swedish, ERSPC) are contaminated. That means that the control groups were tested, diagnosed and treated for prostate cancer, so they are not really 'control' groups.
4) The USPTF largely ignores the fact that when age and medical co-morbidities are factored in, there is a definite survival advantage for screened populations composed of younger and healthier men.
These are just a few of the issues.
We urge men and their primary care providers to carefully examine the risks and benefits of prostate cancer early detection with a PSA blood test and a digital rectal exam. Early detection may save their life. And if early detection doesn't save their life, there is good evidence that early detection may prevent metastatic disease and the devastating side effects of the treatments used for metastatic prostate cancer such as androgen deprivation therapy, chemotherapy and radiation therapy.
Stephen Lieberman, MD, is Chief, Department of Urology, Kaiser Permanente, Northwest Region.