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Abandoning the PSA Test Is a Deeply Flawed Recommendation

A letter to the editor regarding recent changes to the government's prostate cancer screening recommendation

Editor's note: This letter to the editor appeared in the November/December 2011 issue of Missouri Medicine.

To the Editor,

Like almost all urologists, I disagree completely with the recommendation of the government-funded USPSTF panel to abandon PSA screening on men of all ages. I have read Dr. Justin Albani's excellent article (featured in the November/December 2011 issue of Missouri Medicine) and would like to add these comments. (Editor's note: references can all be found in Dr. Albani's article, on the previous page.)

1. The USPSTF has not been a proponent of the PSA test and does not have an urologist, oncologist or radiation oncologist among its ranks. It is chaired by a pediatrician.
   
   
2. The USPSTF Task Force does have a precedence of modifying its proposals based on public outcry such as their controversial mammography screening report. We physicians should generate such an outcry from ourselves and our patients.
   
   
3. The American Urological Association currently has a best practice statement that supports the use of PSA and submits that when used and interpreted appropriately, the PSA test provides important information in the diagnosis, pre-treatment staging, risk-assessment and monitoring of prostate cancer patients.
   
   
4. Urologists still recommend a discussion between a patient and physician regarding the risks and benefits of the PSA test and stress that a biopsy is a very safe procedure in most centers; complications are less than 1 percent. If a prostate cancer diagnosis is made, not all prostate cancers require treatment — active surveillance is a viable option in many men but requires physician counseling.
   
   
5. The USPSTF Evidence Report clearly understates the results of the European Screening Trial that is a large, randomized study reviewing the effect of PSA screening on prostate cancer mortality. It is a very large trial with seven countries involved and showed a 20 percent reduction in mortality in the screened study arm.
   
   
6. The USPSTF Task Force then went on to down play this benefit by saying that it comes with a very high complication rate and quoted dated and unrealistic high complication rates from biopsies and treatment. The study quoted on impotence from radical prostatectomy reviewed a database study from 1995 with no information on whether a nerve-sparing operation was performed. This is a critical piece of information. Further, screening needs to be disconnected in the discussion from treatment and the complications of treatment since one does not automatically lead to the other.
   
   
7. Unbelievably the USPSTF Task Force ignored a large published body of information in which almost every country in the world performing PSA screening has seen a decrease in mortality rates. The recent data from CA for Cancer Clinicians revealed a drop in mortality rates from prostate cancer of 39 percent in the U.S. since the year 2000 when widespread PSA screening started.
   
   
8. Finally, until there is a better widely-available test for the diagnosis of prostate cancer, PSA is one of our most important and least expensive diagnostic tools. PSA remains one of the best tumor markers in the world. Disparaging the PSA test before a suitable alternative is widely available is doing a deadly disservice to millions of men worldwide who may benefit from the early diagnosis of a disease that, once out of the confines of the prostate, is not curable.

I hope this helps clarify some of the issues I, and many other prostate cancer experts, see as erroneous with the USPSTF recommendation.

J. Brantley Thrasher, MD, FACS
Professor & William L. Valk Chair
Department of Urology
University of Kansas Medical Center
Kansas City, Kansas

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