Monday the United States Preventive Services Task Force (USPSTF) came out with recommendations against routine PSA testing for prostate cancer. In the coming days, weeks, and months, this new recommendation is going to resonate amongst men in a myriad of different ways. For those of us who provide primary care to a large population of male patients, that diversity of resonation amongst us has already begun to take place.
Announced in this week’s Annals of Internal Medicine, the new United States Preventive Services Task Force (USPSTF) grade issued for routine PSA testing is a “D,” meaning that there is moderate or high certainty that the service has no net benefit or that the harms outweigh the risk. This recommendation is in contrast to the panel’s 2008 recommendation of D for men 75 years and older and of “I,” meaning that the evidence is insufficient to assess the balance of benefits and harms, for younger men. The change was fueled by the findings of two major randomized trials: the U.S. PLCO (Prostate, Lung, Colorectal, and Ovarian) Cancer Screening Trial and the ERSPC (European Randomized Study of Screening for Prostate Cancer). The U.S. study failed to reveal any benefit in mortality with routine PSA testing, and the European study showed only a marginal benefit in men between the ages of 55 and 69 years.
The controversy surrounding the new recommendation is rooted in the current ambiguity and varied opinions that exist regarding prostate cancer screening. The American Urological Association recommends a baseline PSA with digital rectal exam (DRE) to all men with a life expectancy of 10 years or more at the age of 40. The American Cancer Society recommends that all men make an informed unified decision with their healthcare provider about prostate cancer screening starting at the age of 50. African Americans and those who have a father or brother who had prostate cancer before the age of 65 should make the decision at 45.
If you ask 10 doctors their stance on prostate cancer screening, you would most certainly yield 10 different results. However, what has been agreed upon until Monday is that annual prostate cancer screening is an important discussion to have with all men, as testing is beneficial and will translate to the detection of the potentially fatal disease. The emergence of the USPSTF’s new recommendation now drags this line of thinking into question.
Those who favor the recommendation note it will bring about a reduction in falsely positive screening tests. This in turn will decrease the considerable side effects and mental anguish that accompany diagnostic procedures and treatment of prostate cancer, while having “little to no” changes in prostate cancer-specific mortality. The side effects of diagnostic prostatic procedures include pain, fever, bleeding, and infection, and the side effects of prostate cancer treatment include erectile dysfunction, urinary incontinence, bowel issues, and a small risk of premature death.
Critics of the recommendation cite the poorly defined control groups used in both the U.S. and the European studies and doubt the applicability of the trials to the diverse United States population. Specifically, African American men, who are twice as likely to die of prostate cancer than other men in the United States, were only a mere 4% of the U.S. trial, and racial demographics were not reported in the European study.
Besides adding confusion and controversy amongst physicians and patients, the USPSTF’s recommendation also brings on possible new insurance coverage implications in the face of the Affordable Care Act (ACA). Under the ACA, Medicaid and Medicare will only cover preventive services that are graded as USPSTF class “A” and “B” recommendations. This means that with a grade of D it is possible that PSA testing will not be covered by government-sponsored insurance, and it is not unreasonable to think that commercial insurance providers will likely follow suit.
What do I think? I would say that I fall into the skeptics category regarding the USPSTF’s recommendation against routine PSA (and DRE) testing. The two major clinical studies used, while large and well-conducted, were imperfect in terms of controls, and the patients used cannot be applied to the entire U.S. population. In my opinion, more conclusive information is needed regarding patients with strong family history of disease and African American patients. That being said, I will likely continue to encourage annual PSA testing and DRE in my practice. I would encourage all of you (if male) to have a detailed, personalized discussion with your primary care physician regarding the risks and benefits of screening in order to make a fully informed, collaborative decision.