Oliver Sartor, MD
Screening for prostate-specific antigen (PSA) significantly cuts the death rate from prostate cancer, so America’s medical community should continue to offer the test to appropriate men, but at the same time should work harder to avoid the screen’s potential pitfalls—undertreatment or overtreatment of patients with the disease, said Oliver Sartor, MD, in a talk during the 7th Annual Interdisciplinary Prostate Cancer Congress (IPCC) Saturday in New York City.
“What did the pre-PSA era look like? The American College of Surgeons cancer databases from 1986 through 1988 show that 20% to 21% of patients with prostate cancer were walking in with metastatic disease,”1
said Sartor, Laborde Professor of Cancer Research at Tulane University Medical School in New Orleans, Louisiana, and medical director of the Tulane Cancer Center. “I started [treating] prostate cancer in 1989, and having all these people walk in with metastatic disease was just heartbreaking. We really wanted to do something better than just wait for metastasis to occur.”
Sartor admitted that PSA testing results in both harm and benefit, but said the true concern is not the value of the testing itself, but the undertreatment of men with high-risk prostate cancer and the overtreatment of men with low-risk prostate cancer. In fact, he said, several studies have shown that active surveillance is underutilized and treatment is the norm in low-risk patients in the United States.
“If they are diagnosed,” he said of patients with lower-grade prostate cancers, “they should consult with a physician who is comfortable with surveillance before they decide to be treated.”
PSA screening has long been controversial, and debate has intensified over the past 2 years, since the US Preventive Services Task Force discouraged PSA testing across the board by giving the technique a “D” rating. Sartor questioned that guidance, noting that the USPSTF panel that evaluated the value of PSA testing was led by a pediatric hematologic/oncologist who ostensibly had little or no experience treating prostate cancer.
Meanwhile, a guideline issued by the American Urological Association last year does support PSA testing for certain men between 55 and 69 years of age, and the National Comprehensive Cancer Network last week released a guideline that calls for an initial PSA test between ages 45 and 50, with later testing based on risk factors, and more stringent rules for when biopsy is indicated.
Sartor pointed out that prostate cancer has a high incidence rate as compared to other cancers, at least in part because PSA screening has led to more biopsies being conducted to check men for the disease. Also due to screening, the death rate from prostate cancer has been declining, he said.
While prostate cancer is the second leading cause of cancer death among men, resulting in 28,000 deaths per year, the mortality rate from the condition in men over 50 years is fairly low, at 2% to 3%—and may yet prove to be even lower than that, Sartor said.
“The vast majority of men with prostate cancer will not die from their disease,” he said.
That’s why there’s concern about screening for PSA, which can often result in the diagnosis of prostate cancer long before it is clinically evident—in men 51–56 years old, the lead time was about 12 years, according to one study.2
If men are unnecessarily treated, they often must live with long-term side effects, “a huge issue in prostate cancer,” Sartor said.
Still, he said that a large randomized trial known as the European Randomized Study of Screening for Prostate Cancer (ERSPC)3,4
—an aggregation of data from a host of trials—supported the value of PSA testing.
ERSPC included 182,000 men, with a core group aged 55–69 years. The study compared men whose PSAs were screened every 2 to 7 years against men whose PSAs were not checked. In the unscreened group, prostate cancers were found later and were more likely to be high-risk when they were discovered. The likelihood of men to die of their disease during a follow-up period of more than 10 years was 0.4% in the screened group and 0.5% in the unscreened group.