Policy Change on PSA Screening: A Step Back in the Right Direction

American men need a baseline PSA test and rectal exam to check for prostate cancer in their forties, and then they need follow-up screening at regular intervals – maybe every five years, if the PSA number is low and nothing feels abnormal in the exam, or maybe more often, depending on the number. Men who are at higher risk – men with a family history of prostate cancer and other forms of cancer, and African American men – need to start screening earlier, ideally at age 40.

Have you been screened yet? If not, why not?

Maybe you have health insurance but it’s a terrible policy with a huge deductible – which means you don’t go to the doctor if you can help it, because you know you’ll have to pay out of pocket. Maybe the idea of regular PSA screening seems like a luxury you can’t afford, and you put the money toward your kid’s braces instead.

Or maybe you have decent insurance, but when you asked about getting a PSA test, your doctor pooh-poohed the idea with an explanation like, “The government says you don’t really need it, it leads to unnecessary biopsies, and it doesn’t do any good, anyway.”

The government – actually, the Congressionally funded, policy-setting U.S. Preventive Services Task Force (USPSTF), which has recommended against screening “average risk” men for prostate cancer – has done a big disservice to doctors and their patients. That has been the consensus of many urologists and cancer specialists since 2012, when the latest recommendation to skip PSA screening came out. When that happened, millions of American men stopped getting PSA screening.

Good news: there has been such an uproar in the prostate cancer community that the USPSTF’s bad decision has been reversed.

The USPSTF now says, “The decision about whether to be screened for prostate cancer should be an individual one. The USPSTF recommends that clinicians inform men ages 55 to 69 years about the potential benefits and harms of prostate-specific antigen (PSA)-based screening for prostate cancer.” This is a major change in language and policy, and a major step back in the right direction – although age 55 is too late to start that discussion, just saying.

“Hindsight is 20/20, and there’s no question that when PSA screening first became available, many men were overdiagnosed,” says Edward Schaeffer, M.D., Ph.D., Chairman of Urology at Northwestern University. I recently interviewed him for the Prostate Cancer Foundation’s website, www.pcf.org and he is contributing to the fourth edition of my book with Patrick Walsh, Dr. Patrick Walsh’s Guide to Surviving Prostate Cancer.

Back in the 1990s, when the PSA test first came into widespread use in the 1990s, nobody knew what to do when it looked like there might be prostate cancer; it was not clear what a “safe” PSA level should be. That’s not the case anymore, and doctors are smarter at figuring out who needs to be treated and who can safely take part in active surveillance. In fact, many men with slow-growing prostate cancer don’t need to be treated at all.

So one of the basic assumptions made by the USPSTF – that many men are treated needlessly – is not universally true anymore. Yes, some men are overtreated, but not nearly so many as there used to be, and those numbers keep getting better.

Another basic assumption made by the USPSTF was just dangerously wrong: That all men are the same. They’re not. Some men are a lot more likely to develop prostate cancer, and to develop the bad kind of cancer that really needs to be treated. These are men with a family history of the disease – on either their mother’s or father’s side of the family – and men of African descent. Men who don’t know their family history may be at high risk and not realize it.

“Even among men of average risk, there’s a gradient,” says Schaeffer. “Some men are more likely to develop prostate cancer than other men,” for a host of reasons, including cigarette smoking, obesity, and other environmental factors scientists are still working to understand.

A Disturbing Trend

In recent years Schaeffer, who studies the molecular biology of lethal prostate cancer, has seen a disturbing trend in his patients. They’re not getting diagnosed early, for the two basic reasons mentioned at the beginning of this story; either they have insurance with a very expensive yearly deductible, or they have been told by their family doctor that they don’t need PSA screening.

Concerned, Schaeffer and colleagues at Northwestern decided to “look at the landscape of men who are newly diagnosed with prostate cancer in the U.S.” To get the bigger picture, they looked at all men diagnosed with prostate cancer in the National Cancer Data Base from 2004 to 2013 at nearly 1,100 different medical centers in the U.S. They found something other scientists had noted, declining rates in the diagnosis of low-grade, localized prostate cancer (after a bubble in the 1990s when PSA screening was introduced, and thousands of men with cancer that was never diagnosable before).

But they also found something unexpected: “We saw that there was a sharp increase in the number of men newly diagnosed with metastatic prostate cancer.”  This observation has been supported by work analyzing advanced, more aggressive prostate cancers among men in another national cancer registry called SEER. Jim Hu, a urologist from Cornell, also noted that over the last several years – a time when PSA screening dropped – more men were being diagnosed with aggressive and advanced cancers.

“The number of men being diagnosed with metastatic prostate cancer is rising, says Schaeffer. “It went up from 2007 to 2013, and in 2013, it was 72 percent higher than it was in 2004. The greatest increase in metastatic prostate cancer was in men between the ages of 55 and 69; it was 92 percent higher in 2013 than in 2004.” The findings can’t be explained completely by the USPSTF recommendations alone, he notes. Environmental factors may be responsible for the general rise in metastatic disease. For example, we now know that being overweight makes men more likely to develop aggressive prostate cancer, and to die of it. Smoking and diet play important roles here, as well.

But clearly, not detecting prostate cancer early – a tactic proven to save lives in European studies – is taking a toll, Schaeffer says. “We need nationwide refinements in prostate cancer screening and treatment to prevent men from being diagnosed with metastatic prostate cancer. We don’t want to diagnose low-grade cancers,” which may never need to be treated. “But we really need to pick up the disease before it becomes metastatic.”

In addition to the book, I have written about this story and much more about prostate cancer on the Prostate Cancer Foundation’s website, pcf.org. The stories I’ve written are under the categories, “Understanding Prostate Cancer,” and “For Patients.”  As Patrick Walsh and I have said for years in our books, Knowledge is power: Saving your life may start with you going to the doctor, and knowing the right questions to ask. I hope all men will put prostate cancer on their radar. Get a baseline PSA blood test in your early 40s, and if you are of African descent, or if cancer and/or prostate cancer runs in your family, you need to be screened regularly for the disease. Many doctors don’t do this, so it’s up to you to ask for it.

 ©Janet Farrar Worthington