Issue link: https://viewer.e-digitaledition.com/i/138456
+++++++++++++++++++++++++++++++++++++++ + +++ + MEN'S HEALTH SPECIAL SECTIoN +++ +++++++++++++++++++++++++++++++++++++++ Understanding Prostate screening by David turk, mD W HEN THE U.S. Preventive S er v ices Ta sk Force (USPSTF) made its recommendation against any routine use of the prostate-specific antigen (PSA) screening, controversy arose leaving many physicians confused and others outraged. The core argument of the USPSTF recommendation is that the PSA test "has potential to harm more individuals than it could help." Much has been debated over the past year, and even more recently, the American Urological Association (AUA) issued new guidelines on PSA screening. "Aside from non-melanoma skin cancer, prostate cancer is the most common cancer among men in the U.S.," according to the Centers for Disease Control and Prevention (CDC). The CDC states that prostate cancer "is also one of the leading causes of cancer death among men of all races." Prior to the Food and Drug Administration's approval of the PSA screening test in 1994, prostate screening relied primarily on digital rectal exam (DRE). Several large series; however, have demonstrated that only 30% of cancers detected by DRE are organ-confined and potentially curable. The USPSTF based its recommendation on several facts. The first was that very few men die of prostate cancer before age 60, and 70% of men die of prostate cancer after age 75. They noted that many men are diagnosed with asymptomatic prostate cancer or "pseudo-disease," and overdiagnosis rates are between 17–50%. The group also claimed that only zero to one out of 1,000 men avoided prostate cancer death as a result of screening. Additionally, the screening resulted in harms related to screening and diagnostic procedures as well as harms related to treatment of asymptomatic prostate cancer. The USPSTF concluded that the benefits of PSA-based screening do not outweigh the harms, and the group subsequently issued a "D" recommendation. Arguments against the USPSTF recommendations include that the definitive conclusions were based on incomplete data where the cited European Randomized Study of Screening for Prostate Cancer had a median follow-up of only nine years. Another argument was that the data was combined from incompatible trials conducted under different conditions. Urologists argued that the panel did not include any urologists or cancer specialists. The task force failed to make recommendations for at-risk groups, such as individuals with immediate family members with prostate cancer and African-Americans. Many urologists recognize that treatment may carry serious risk, and the urology community is actively redefining which patients should be undergoing active surveillance and which patients should be aggressively treated. It is noted that the USPSTF recommendation has focused on mortality rather than morbidity. While PSA testing in the U.S. has resulted in a reduction of prostate cancer mortality by 20–30%, most urologists diagnose prostate cancer in order to decrease mortality and morbidity. Morbidity from prostate cancer includes painful metastases, urinary obstruction, asthenia, fatigue and renal failure. Diagnosing prostate cancer early has been shown to significantly delay morbidity and improve quality of life. The AUA issued new guidelines in May 2013, based on a rigorous systematic literature review by a multidisciplinary team involving medical and radiation oncologists, general internists, epidemiologists and urologists. The new guidelines state that men 55 to 69 years of age who are at average risk and asymptomatic can consider PSA screening. Physicians should speak with their patients about the benefits and harms of testing to determine the best course of action. PSA testing is not recommended for men under age 40, for men 40–54 years who are at average risk, for men over 70 years, or for men with a life expectancy of less than 10-15 years. However, it is recommended that men in these age groups who are at higher risk for prostate cancer speak to their physician about the benefits and risks of PSA testing. Clearly, physicians must continue to have meaningful discussions with their patients to determine appropriate screening. Dr. David Turk is Chairman, Department of Surgery at Southwest General and a partner in SouthWest Urology Inc. ■