Study questions value of PSA test for older men

Only a third who received abnormal result went on to receive prostate biopsy, experts note.

06 may 2013—Only one-third of men over age 65 who receive an abnormal result from their PSA test actually undergo prostate biopsy to look for disease, a new study finds.

Prostate-specific antigen (PSA) screening is a common test that measures the level of a key marker for prostate cancer in the blood. In general, the higher the level of this protein, the more likely it is that a man has prostate cancer, according to the U.S. National Cancer Institute.

The value of the PSA test has recently come into question, however, with several studies suggesting it causes men more harm than good —spotting too many slow-growing tumors that, especially in older patients, may never lead to serious illness or death.

The new study focused on this issue once again, tracking outcomes for nearly 300,000 men, aged 65 and older, who underwent PSA screening in the U.S. Veterans Affairs health care system in 2003. The men's health was followed for up to five years.

There were more than 25,000 men with clinically abnormal PSA levels. According to the study authors, during the five-year follow-up period, only 33 percent of those men underwent at least one prostate biopsy to check for evidence of cancer. About 63 percent of those who did have a biopsy were diagnosed with prostate cancer, of whom 82 percent were treated for their cancer.

The older the man, the less likely he was to have a prostate biopsy after having an abnormal PSA screening test result. Men with other health problems were also less likely to undergo a prostate biopsy, the investigators reported.

The study was published online April 15 in the journal JAMA Internal Medicine.

Among men with biopsy-detected prostate cancer, the risk of death from causes other than prostate cancer increased with age and with the presence of other health problems, Dr. Louise Walter, of San Francisco Veterans Affairs Medical Center, and colleagues pointed out in a journal news release.

Two experts not connected to the study said the findings weren't surprising, given the patients' ages.

"PSA screening has been controversial as it has a relatively low yield for finding clinically significant cancer as well as potential 
complications and expense related to diagnosis and treatment," said Dr. Louis Kavoussi, chairman of urology at North Shore-LIJ's Arthur Institute for Urology in New Hyde Park, N.Y.

In the new study, "as age and other chronic illnesses of aging increased, the less likely biopsy was performed," he said. "This makes sense as the authors report that older individuals and those with [other illnesses] are more likely to die of a non-prostate cancer-related cause."

Therefore, the decision to test for PSA levels in older men must take into account their relatively low risk of dying of prostate cancer, Kavoussi said. "Overall, it is known that about 10 percent of individuals diagnosed with prostate cancer succumb to the disease," he said. "In this older patient population study it was 2.2 percent—much lower, but not zero."

Another expert agreed, saying that younger men may benefit most from regular PSA screening.

"For screening to be effective, we need to focus on men with a long life expectancy," said Dr. Stacy Loeb, assistant professor in the department of population health at NYU Langone Medical Center, New York City. "Screening allows us to diagnose the life-threatening cancers in time for cure [but] diagnosis does not mandate treatment," she explained.

"Once a diagnosis is made, many patients with low risk disease can be safely monitored conservatively," Loeb said. "Men should be actively involved in all of these choices, with a discussion about risks and benefits."

What's really needed, according to Kavoussi, is a screen that can tell a patient whether his prostate cancer is aggressive or not.

There's a "need for better ways of detecting clinically significant disease in this older population, both to avoid overtreatment and to minimize the risk of missing significant disease," Kavoussi said.

More information: The U.S. National Cancer Institute has more about prostate cancer screening.

Final word: Task force recommends against PSA-based screening for prostate cancer

Following a period for public comment, the United States Preventive Services Task Force (USPSTF) released its final recommendation for prostate cancer screening. The Task Force now recommends against PSA-based screening for all men, regardless of age. The final recommendations are being published early online in the May 22 issue of Annals of Internal Medicine, the flagship journal of the American College of Physicians (ACP).

12 jun 2012--The Task Force last published recommendations on prostate cancer screening in 2008. At the time, researchers concluded that there was no evidence to support PSA testing for men over the age of 75. An independent panel of experts reviewed evidence published since 2008 and concluded that the harms of PSA testing outweigh the benefits regardless of age. The Task Force considers health benefits and harms, but not costs, when developing recommendations.
The primary goal of prostate cancer screening programs is to save lives and prevent symptomatic disease. The Task Force considered two major trials of PSA testing in asymptomatic men to assess the life-saving benefits of PSA testing. The first trial, conducted in the U.S., did not demonstrate any prostate cancer mortality reduction as a result of screening. The second trial, conducted in seven European countries, found a reduction in prostate cancer deaths of about one death prevented per 1,000 men screened in a subgroup of men aged 55 to 69 years, mostly in two countries. Five of the seven countries reporting results did not find a statistically significant reduction in deaths.
Strong evidence shows that PSA screening is associated with significant harms. Nearly 90 percent of men with PSA-detected prostate cancer undergo early treatment with surgery, radiation, or androgen deprivation therapy. Evidence shows that up to five in 1,000 men will die within one month of prostate cancer surgery and between 10 and 70 men will survive, but suffer life-long adverse effects such urinary incontinence, erectile dysfunction, and bowel dysfunction.
According to William J. Catalona, M.D., Medical Director of the Urological Research Foundation and author of an accompanying editorial, the Task Force recommendation has underestimated the benefits and overestimated the harms of prostate cancer screening. He and his co-authors argue that the Task Force -- whose panel does not include urologist or cancer specialists -- largely bases its recommendations on flawed studies with inadequate follow up time. In addition, the Task Force recommendations focus on mortality and do not take into consideration the substantial illness related to living with advanced cancer.
Editorial co-author, Dr. Henry Lynch, Director of the Hereditary Cancer Center at Creighton University, adds that the Task Force recommendations also leave out high-risk populations and younger men. The authors express concern that the new recommendations will take Americans back to an era when prostate cancer was often discovered at advanced, incurable stages.
"The recommendations of the USPSTF carry considerable weight with Medicare and other third-party insurers," Dr. Lynch said. "My colleagues and I strongly believe that the Task Force recommendations should not be used as justification by insurers, including Medicare, to deny diagnosis of prostate cancer to the male population at risk."
Yet, according to Otis W. Brawley, MD, MPH, Chief Medical Officer of the American Cancer Society, and author of a second accompanying commentary, overdiagnosis makes screening seem to save lives when it truly does not. Many men are diagnosed with prostate cancer that may never have progressed within their lifetime. Yet because they were screened and treated, they think screening saved their lives.
"Many people have a blind faith in early detection of cancer and subsequent aggressive medical intervention whenever cancer is found," wrote Dr. Brawley. "There is little appreciation of the harms that screening and medical interventions can cause."
In October 2011, the Task Force posted its draft recommendations for public comment. At the time, the Task Force had given PSA screening a grade "D," meaning that physicians should not offer the test because the harms outweigh the benefits. Many people who commented on the recommendations urged the Task Force to change the recommendation to a grade "C," meaning physicians could provide the test to patients who request it. However, no new evidence was presented. The recommendation remains unchanged.
While the recommendation clearly states that physicians should not offer PSA screening, the Task Force says it leaves the ultimate power in the hands of the health care providers.
"The USPSTF recognizes that clinical, policy, and coverage decisions involve more considerations than evidence alone," said Task Force Chair, Virginia A. Moyer, MD, MPH of Baylor College of Medicine in Houston, TX. "Clinicians and health care providers should understand the evidence but individualize decision-making to the specific patient or situation."
Provided by American College of Physicians

Guidelines for prostate screening widely ignored

New research confirms that the controversial decision by Warren Buffet – the 81-year-old CEO of Berkshire Hathaway – to undergo a blood test screening for prostate cancer despite his age is hardly unusual. Despite recommendations in 2008 from the United States Preventive Services Task Force against testing for prostate cancer in men aged 75 years or older, almost half of men in that age group continue to get screening tests.

26 april 2012--In 2005, before the recommendations were released, 43 percent of men age 75 and above elected to take the prostate-specific antigen (PSA) test. In August 2008, the Task Force stated it "recommends against the service," arguing "there is moderate or high certainty the service has no net benefit or that the harms outweigh the benefits."
Survey results from 2010, however, published in the April 25, 2012, issue of JAMA, found that two years after the Task Force's recommendations were announced, the screening rate for that group of men had gone up slightly, to 43.9 percent. This is higher than the rates for men in their 40s (12.5 percent) or 50s (33.2 percent), who are more likely to benefit from early diagnosis and treatment. Only men aged 60 to 74 were more likely to get the screening test (51.2 percent).
"PSA screening for more than 40 percent of men 75 or older is inappropriate," said study author Scott Eggener, MD, assistant professor of surgery at the University of Chicago Medicine. "Selective screening is reasonable to consider for the healthiest men over age 75, but for the large majority of men in this age group, early detection can lead to treatment of a disease that will probably never cause a problem. A substantial proportion of men over 75 with an elevated PSA will die from something else before a prostate cancer interferes with the quality or duration of their life."
"Our data are likely an underestimate," the authors note. They worked with information from the 2005 and 2010 Cancer Control Supplements, part of the annual National Health Interview Survey (NHIS), which gathers information through in-person interviews and is a representative sample of the US population. "Self-reported screening rates in the NHIS," they note, "are predominantly lower compared with medical record extraction."
The revised draft recommendations presented in October 2011 by the USPSTF are even more critical of PSA screening than the 2008 version, suggesting there was not enough evidence that PSA screening improves health outcomes to routinely recommend the test for men at any age. "Prostate-specific antigen–based screening results in small or no reduction in prostate cancer–specific mortality," the Task Force concludes. It is associated with "harms related to subsequent evaluation and treatments, some of which may be unnecessary." These draft recommendations are not finalized yet but are expected to be forthcoming soon.
Clinical practice patterns following the 2011 USPSTF recommendations "should be monitored," the study authors conclude. Even if PSA screening is discouraged in the final USPSTF recommendation, "I'm not anticipating a massive change in utilization," Eggener said, based on a general tendency for individuals and physicians to support cancer screening, evidence that fewer men are dying of prostate cancer since the introduction of PSA, subsequent confusion about the recommendation among the general public, and ongoing concern about the disease.

Provided by University of Chicago Medical Center

Prostate test 'public health disaster': discoverer

WASHINGTON,14 mar 2010– The most commonly used tool for detecting prostate cancer, routine PSA screening, has become "a hugely expensive public health disaster," its discoverer said on Wednesday.

Dr. Richard Ablin of the University of Arizona joined the ongoing debate over the blood test, saying the screening procedure is too costly and ineffective.

"I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster," Ablin wrote in a commentary for The New York Times.

Ablin said that as Congress searches for ways to cut costs in the U.S. health care system, a significant savings could come from changing the way PSA is used.

"The test's popularity has led to a hugely expensive public health disaster," he wrote.

He said the annual bill for PSA screening is at least $3 billion, with much of it paid for by Medicare and the Veterans Administration.

"As I've been trying to make clear for many years now, PSA testing can't detect prostate cancer and, more important, it can't distinguish between the two types of prostate cancer -- the one that will kill you and the one that won't," he wrote.

"Instead, the test simply reveals how much of the prostate antigen a man has in his blood."

Prostate cancer is the second most common cancer in men worldwide after lung cancer, killing 254,000 men a year.

PSA is a protein made only by prostate cells, and levels can shoot up as a prostate tumor proliferates. But levels can also rise as the prostate naturally enlarges with age.

A high PSA reading is usually followed by a biopsy, which is a sample of the prostate tissue taken and examined for signs of a tumor.

SLOWLY TURNING AGAINST

Doctors have routinely recommended PSA tests to men over 50 in the belief that early diagnosis and aggressive treatment for any cancer is better than standing by and doing nothing.

But prostate cancer can often be a slow-growing tumor and men will often die of something else before the cancer becomes dangerous.

Prostate cancer treatments, including surgery or radiation, can cause incontinence and erectile dysfunction in about a third of patients. Many men also experience bowel problems.

Citing recent studies and reversals of some early screening proponents, Ablin said the medical community is slowly turning against PSA screening.

"So why is it still used? Because drug companies continue peddling the tests and advocacy groups push 'prostate cancer awareness' by encouraging men to get screened," Ablin wrote.

Ablin said PSA testing does have a place, after treatment for prostate cancer and for men with a family history of prostate cancer.

"Testing should absolutely not be deployed to screen the entire population of men over the age of 50, the outcome pushed by those who stand to profit," Ablin wrote.

He urged the medical community to "confront reality and stop the inappropriate use of PSA screening."

More evidence prostate tests overdiagnose cancer

WASHINGTON, 17 mar 2009 -- As many as two of every five men whose prostate cancer was caught through a PSA screening test have tumors too slow-growing to ever be a threat, says a new study that raises more questions about the controversial tests.

The work "reinforces the message that we are overdiagnosing prostate cancer," said Dr. Len Lichtenfeld of the American Cancer Society, who was not involved in the new study.

More than 186,000 U.S. men will be diagnosed with prostate cancer this year, and nearly 29,000 will die, according to cancer society estimates. Most men over 50 have had a blood test that measures prostate specific antigen, or PSA, mostly for routine screening.

There begins the list of problems: Most men who undergo a biopsy for an abnormal PSA test don't turn out to have prostate cancer; high PSAs often signal a benign enlarged prostate. Of those who do have cancer, there's no proof yet that early detection saves lives _ as most prostate tumors grow so slowly that had they not been screened, those men would have died of something else without the anxiety.

How many? Estimates vary widely. Enter the new study, which tracked prostate cancer diagnosed in U.S. men ages 54 to 80 between 1985 and 2000, and used three different models developed by cancer centers to more accurately estimate overdiagnosis.

Depending on how it's calculated, anywhere from 23 percent to 42 percent of PSA-detected cancers would otherwise never have been detected in the man's lifetime, concluded the team led by researchers at Erasmus University Medical Center in the Netherlands.

The study was published online Tuesday by the Journal of the National Cancer Institute.

Why is overdiagnosis such a concern? Because finding an early tumor forces men to choose among contested treatments _ "watchful waiting," surgery, hormone therapy, radiation. And because some treatments can cause incontinence and impotence, men whose tumors wouldn't have been a threat can suffer serious side effects for no gain.

In fact, national health guidelines issued last year said men over age 75 shouldn't undergo PSA screening, while younger men should make an individual choice after hearing the pros and cons and weighing their own cancer risk.

The new study's estimate of U.S. overdiagnosis probably is too low _ because since 2000, doctors have begun performing biopsies for lower PSA levels than once were the trigger, wrote Dr. Michael Barry of Massachusetts General Hospital in an accompanying editorial.

It's a confusing issue, acknowledged the cancer society's Lichtenfeld.

It boils down to: "If we diagnose this disease, are we making your life better? We know that for other cancers," such as breast, cervical and colorectal, which have strong evidence showing early detection hugely improves survival, he said.

Major studies are under way that in a few years should offer better guidance for prostate cancer screening, and scientists are furiously hunting new tests that might help pinpoint who has a worrisome tumor and who can relax.

"We're waiting for that evidence. Hopefully we'll have it in the not too distant future, but we really don't have the best answer right now," added Lichtenfeld, who stressed the importance of discussing potential benefits and risks with a doctor.