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special clinical secTion: meN'S heAlTh A Way Forward for more Than one year afTer The release of The u.s. prevenTive services TasK force (uspsTf) final recommendaTion againsT TesTing for prosTaTe-specific anTigen (psa), The QuesTion of how besT To idenTify and TreaT prosTaTe cancer conTinues To Trouble The medical communiTy. P approved by the U.S. Food and Drug Administration in 1986, and a spike in identified prostate cancer cases immediately followed. From 1991 to 2006, mortalities caused by prostate cancer declined 40 percent, a trend credited in part to the rapid adoption of PSA screening in the United States. Despite this track record, the USPSTF claims the screening often leads physicians to recommend invasive — and sometimes unnecessary — procedures, such as biopsies and radiation therapy, following detection of high PSA levels. The USPSTF cites side effects of such diagnostic tests and treatments — including erectile dysfunction, urinary incontinence and infection — in its recommendation. Though prostate cancer is the second most common form of cancer found in men, aggressive cases with a Gleason score of or close to 10 are relatively rare. It is much more common for men to have a slow-growing form of prostate cancer that has little potential for spreading and poses a low immediate health risk. Still, it's 14 SA SCReeNING WAS | Mid Hudson MD News ■ mDNeWS.Com estimated that 29,720 men will die from prostate cancer in 2013. An unmet Need Several organizations and practitioners find fault with the USPSTF's recommendation because it creates a cancer screening void for patients who have neither a diagnosis nor an elevated risk of prostate cancer but could be silently living with the disease. "What we've seen since the recommendation is virtually every associated professional medical group disagreeing with the USPSTF," says Jan Manarite, Senior Educational Facilitator for the Prostate Cancer Research Institute. "I've also had callers who have been diagnosed with prostate cancer who are disillusioned because [they are uncertain how the decision will affect them]." While the complications detailed by the USPSTF are legitimate concerns, they are something Matthew Cooperberg, MD, MPH, Assistant Professor of Urology at the University of California, San Francisco, describes as a worst-case scenario often associated with centers that do not perform a high volume of prostate cancer procedures and lack the specialized expertise to effectively and safely care for patients with prostate cancer. Smarter Screening The ongoing discussion about prostate cancer screening makes it clear there is no simple answer to the PSA problem. It's a complex issue that calls for more complete understanding of each patient's individual circumstances and risk factors alongside individualized screening strategies, a situation that PSA supporters say calls not for less screening, but for smarter screening. A Fred Hutchinson Cancer Research Center and University of Washington study, "Comparative Effectiveness of Alternative Prostate-Specific AntigenBased Prostate Ca ncer Screening Strategies," published in Annals of Internal Medicine in February 2013 examined 35 PSA screening strategies and identified two specific patterns that maintained a similar prostate cancer detection rate but also lowered the likelihood of overdiagnosis. According to the study, by increasing the required PSA level for biopsy referral

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