A panel of experts provides their thoughts on the USPSTF PSA screening recommendations, and how this widely publicized health message has impacted their urology practices.
Raoul S. Concepcion, MD
Editor-in-Chief, Urologists in Cancer Care
Director of Clinical Research,
Urology Associates, PC
Nashville, Tennessee Mark S. Austenfeld, MD
Kansas City Urology Care
Saint Luke’s Hospital
Kansas City, Missouri
E. David Crawford, MD
Head, Urologic Oncology
University of Colorado
Neal D. Shore, MD
Director, Carolina Urologic
Grand Strand Urology/Atlantic
Myrtle Beach, South Carolina
Paul R. Sieber, MD
Urological Associates of Lancaster
In May 2012, the US Preventive Services Task Force (USPSTF) recommended against PSA screening for prostate cancer in men regardless of age, citing evidence of a very small potential benefit from screening and significant potential harms.
In the aftermath of this recommendation, a number of medical organizations issued formal statements of disagreement, including the American Urological Association (AUA), which stated in part that “…the PSA test provides important information in the diagnosis, pretreatment staging or risk assessment and monitoring of prostate cancer patients….”
Editor-in-Chief of Urologists in Cancer Care, Raoul S. Conception, MD, Director of Clinical Research at Urology Associates, PC, in Nashville, Tennessee, moderated a panel discussion with physicians (see sidebar for the full list of panelists) as part of a video series from the Urologists in Cancer Care Peer Exchange program.
As part of a more extensive discussion about clinical and practice management issues that urologists face, Concepcion asked panel members for their thoughts on the USPSTF recommendations, and how this widely publicized health message has impacted their urology practices.
Concepcion: Let’s talk about prostate cancer screening. We know that the United States Preventive Services Task Force came out recently with a very controversial recommendation regarding PSA screening for prostate cancer. Dr Crawford, let’s start with you.
Crawford: My short answer is that there is a lot of truth in what they say. In 1989, we started one of the biggest organized national prostate cancer screening events, Prostate Cancer Awareness Week, which has been in place ever since. Millions of men have been screened, and we have learned a lot. Where we got into trouble was by diagnosing people who maybe did not need to be diagnosed and treated. The bottom line is that we need to separate diagnosis from treatment. Not everyone who is diagnosed needs to be treated.
If you don’t believe in overdiagnosis and overtreatment…I can say that I see it all the time. Patients come in with a PSA of 45 and Gleason score of 6 in one core, and they get a robotic prostatectomy or IMRT [intensity-modulated radiation therapy]. Does this person really need to be treated?
I am not sure that we should be attacking the USPSTF. We should find some common ground and work on better ways to identify who needs to be screened.
Concepcion: Dr Austenfeld, like most of us, you wear multiple hats. Could you comment with your American Association of Clinical Urologists (AACU) hat as well as your clinician’s hat as a key part of a large urology group?
Austenfeld: I think most of urologists in this country feel that the USPSTF overstepped its bounds and didn’t listen to some of the expert opinion and advisory groups, particularly the AUA and experts who were able to break down some of the studies. They only used two studies primarily, and the follow-up was short.
And, as we know, there were neither oncologists nor urologists on the panel. It is true that they may have some biases, but there are a great number of researchers in urology in this country who can give a good and unbiased professional opinion about this. Also, the Task Force had a chance to go back and revise its recommendation and didn’t. I think most people feel they plowed ahead without really good data, or at least [interpreted] the data incorrectly.
I agree with David that we probably diagnose too many men with prostate cancer, and some are overtreated. But we can’t ignore the fact that the death rate from prostate cancer has declined from the early days of PSA screening. We also can’t deny the fact that many men who suffer from prostate cancer live for many years before they die from the disease. So, death from prostate cancer as an endpoint is probably not very good.
The last thing I would say is that men I have seen in my practice are confused by this recommendation. I think it’s going to be our role to come up with a little more balanced assessment of prostate cancer screening or case-finding.
Concepcion: The egregious thing about this is that the USPSTF tied together early diagnosis and over-treatment, and these are two separate entities. Just because there is overtreatment, it doesn’t mean that the patient does not have the right to know that he has prostate cancer at a very early stage.
Crawford: That’s what we’ve been saying at Prostate Cancer Awareness Week for two decades. Know what you have so you can choose a treatment, or maybe choose to do nothing. The unfortunate thing is that a lot of time when men are diagnosed, the “train has left the station.” We give a lot of lip service to active surveillance, but if you look at the numbers of men who go onto active surveillance, it’s way less than 10%, and it’s decreasing rather than increasing.
Concepcion: Dr Shore, since the USPSTF recommendation, tell us a little bit about how this has impacted your practice—with referring doctors and how they have responded, and what patients say when they come in to see you and your partners in Myrtle Beach.
Shore: The Task Force gives its recommendation a “D” rating. And, based on the news that went out into the mass media, the interpretation by many of my patients was that “I don’t really need to have PSA testing; it is really unnecessary. No one dies from prostate cancer.” We all know that this is not the situation. So I think it’s created terrible misinformation in the public mind. I don’t think the Task Force wanted to do that; I think they were trying to address issues of overdiagnosing and perhaps overtreatment, which are very valid issues, and I wouldn’t argue with that. I don’t think that any of us would. But it’s created terrible misinformation in my clinic population.
We have also seen a decline in our referrals from our primary care base. And, as someone who is very involved in treating systemic prostate cancer in patients who fail localized therapy, I am concerned that a future trend could be that we will see more patients who are not appropriately diagnosed, and not appropriately screened but who are at high-risk for prostate cancer (eg, positive family history, African-American individuals, those who have had industrial chemical exposure, rapid PSA elevation). We may end up seeing more patients presenting to our clinics with advanced disease. As we all know, prostate cancer is the second leading cause of cancer mortality in men in the United States, after lung cancer. So, I have real concerns about it. We need to more judiciously know whom to screen, whom to diagnose, and whom to biopsy. But it’s not a one-size- fits-all [situation], and the Task Force recommendation, at least for my patient population, has presented this as a one-size-fits-all concept.
From a legislative standpoint, we are also concerned that with this type of a recommendation, there could be a failure to pay for PSA testing in the future. Although Department of Health and Human Services Secretary Kathleen Sebelius has said that this is not the case right now, she or her successor has the option to no longer pay for it. This is very disconcerting.
Sieber: I would echo Neal’s comment: I spend more time each day explaining—even in patients with prostate cancer—that the PSA test is not invalid. [The task of communicating this] is an overwhelming burden. The gripe I have with the Task Force is that I don’t think they understand the weight of what they said in terms of how the average man is going to see a front-page headline and interpret it. This has led to a significant burden in our office to talk to our patients.