Govt. Panel Scuttles Prostate Cancer Testing Recommendations

A governmental advisory panel says most men should not get the PSA blood test.

ByVERONICA SIKKA M.D., ABC News Medical Unit
May 21, 2012, 5:17 PM

May 21, 2012— -- The governmental advisory panel tasked with issuing cancer screening guidelines made a final recommendation on the most common form of prostate cancer screening, PSA tests.

The panel's ruling: Not needed, regardless of age.

On Monday, the United States Preventive Services Task Force, or USPSTF, put forth this guideline on prostate-specific antigen (PSA) blood tests, which more than 20 million American men get each year. The formal recommendation follows draft guidance the task force issued in October 2011. These guidelines drive the screening decisions of doctors throughout the country.

The PSA blood test is the traditional way to detect evidence of prostate cancer, which is the most common cancer diagnosed in American men. The National Cancer Institute estimates that in 2012, almost 250,000 new cases and more than 28,000 prostate cancer-related deaths will occur.

The task force maintains that PSA tests do more harm than good. Dr. Michael LeFevre, co-vice chairman of the task force, said the medical procedures arising from the tests could have serious downsides, including blood clots, heart attacks, strokes and possibly death. Other complications include impotence and urinary incontinence.

"Of 1,000 men who are screened, at most one man will avoid a prostate cancer death," LeFevre said. "Two to three will have blood clot, heart attack, stroke or even death from treatment of the prostate cancer. One in 3,000 men screened will die of surgical complications from the treatment."

Paul Nelson, 51, knows firsthand the feeling of getting a postive PSA test. He was diagnosed five years ago.

"Panic was the number one thing in my mind," he told ABC News Chief Health and Medical Editor Dr. Richard Besser. "And the doctors were like, 'The only way to make sure you're done is to get it out.'"

Now the president of the Erectile Dysfunction Foundation, Nelson said not enough men know about the side effects of the procedures that follow a positive PSA test.

"The doctors wouldn't talk about it," he said. "There was nothing on the Internet."

The medical community is split on the new recommendation. And most urologists -- the doctors who arguably treat the most cases of prostate disease -- do not agree with the task force's guidelines.

"PSA screening is the only test we have," said Dr. William Catalona, a professor of urology at Northwestern University. "The great majority of doctors who deal with prostate cancer patients believe that the task force underestimated the benefits and overestimated the harms. Perhaps it is because none of the Task Force members were urologists."

"There is no mention of the dramatic decline in the number of men with advanced prostate cancer," said Dr. Patrick Walsh, professor of urology at Johns Hopkins University. "In 1990, 21 percent of men at diagnosis had metastatic prostate cancer to bone. Today it is 4 percent. This is clearly a dramatic effect of PSA testing.

"[The new recommendations] fail to recognize that in the absence of PSA testing, a man will not know that he has the disease until he has symptoms, at which time the cancer is too far advanced to cure," Walsh said.

And Dr. Gerald Andriole, chief of urology at Washington University School of Medicine, called the task force's recommendations "too draconian on categorically dismissing PSA."

"In some respects we have not been using PSA as well as we could," Andriole said. "However, to post a headline that says 'No More PSA Testing' is throwing the baby out with the bathwater."

Primary care physicians differed on whether the recommendations are a good idea. Some, like Dr. Jacques Carter, assistant professor of medicine at Harvard Medical School, insisted that "screening for prostate cancer saves lives." Others, like Dr. Jim Jirjis, director of adult primary care at Vanderbilt University, said they had already begun to recommend against the tests.

"I inform the patients that it is not an ideal screening test and that the USPSTF [task force] is recommending against it," Jirjis said. "Many patients ... decline after I explain."

Still others said that the decision needed to be made on a case-by-case basis.

"I agree that screening for prostate cancer in men in general is a bad idea," said Dr. John Messmer, associate professor of family and community medicine at Penn State Hershey College of Medicine. "That being said, the possibility of obtaining a PSA on a man with particular circumstances should still be an option."

As for the millions of middle-aged and older men who find themselves in the middle of this debate, the consensus among the physicians is for them to communicate openly with their doctors.

"This does not preclude a patient from asking for the test and the physician offering the test," said LeFevre. "There should be an open and honest discussion with significant known harms."

And while the USPSTF's recommendations may drastically reduce the number of men who undergo a PSA blood test, those considered to have a strong family history of prostate cancer -- in other words, more than one first degree relative with prostate cancer before the age of 69 -- may still want to consider getting it.

"The key is informed decision-making," said Dr. Otis Brawley, chief medical and scientific officer of the American Cancer Society. "In the physician-patient relationship, men should be informed of the known risks and potential benefits and be encouraged to make a choice."

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