Friday, June 15, 2012

The Controversy Over Prostate Cancer Screening

By The Physicians of Urology Centers of Alabama

Prostate cancer is the most commonly diagnosed non-skin cancer and the second leading cause of cancer death in American men. One in nine men will develop prostate cancer.
Contrary to common belief, prostate cancer iis not just a disease of the elderly. The disease affects one in 15 men from ages 60 to 69. Those with a family history and African Americans are at the greatest risk. Screening for prostate cancer consists of a simple blood test called a “PSA” and a rectal examination. Generally, men ages 40 to 75 are the candidates for screening.
Since the PSA test came into widespread use for early detection by the mid-1990s, the
death rate due to prostate cancer has fallen by almost 40 percent. Despite this, there is much controversy regarding screening for prostate cancer. The screening is not “perfect,” but no “screening” is, nor is intended to be. The success of prostate cancer screening is similar to that of screening mammography for breast cancer and colonoscopy for colorectal cancer.
Adding to this controversy is the recommendation by the U.S. Preventive Services Task
Force (USPSTF) against prostate-specific antigen (PSA) based screening for prostate
cancer released on May 21, 2012. The USPSTF is “an independent panel of non-Federal experts” funded by the US Department of Health and Human Services.
We believe that the above recommendation is substantially flawed and support this statement with the following facts:
· Since the PSA test came into widespread use for early detection by the mid-
1990s, the death rate due to prostate cancer has fallen by almost 40 percent.
· 90% of all prostate cancers are now confined to the prostate gland (likely curable)
at the time of diagnosis. Prior to PSA screening, only 30-40% of prostate cancers
were curable at discovery.
· This decision is coming from a “panel of experts” with no urologists, medical
oncologists or radiation oncologists, the physicians most familiar with prostate
· One of the most influential studies cited by the USPSTF is the PLCO study
published in the New England Journal of Medicine in March 2009. Many flaws
were found with this study, including the fact that the median follow up of the
“unscreened” patients was 5.2 years (far too short to see many deaths from
untreated prostate cancer), 40% of the “unscreened” patients had actually had a
normal PSA prior to entry into the study (therefore they were actually “screened”)
and 33% of patients were lost to follow-up and not included in the data analysis.
· A second influential study from Europe, the European Randomized Study of
Screening for Prostate Cancer (ERSPC), also in the NEJM in March 2009,
showed “only” a 20% reduction in death rate in screened patients (median
follow-up was almost 7.5 years, long enough to start seeing an impact of
screening). Analyzing only these study patients with the longest follow-up (over
10 years), the decrease in death rate rose to 38%.
· The results of the Göteborg Randomized Population-based Prostate Cancer
Screening Trial, a 14 year Swedish study partially funded by the National Cancer
Institute (July 2010), showed a 44 percent decline in prostate cancer deaths as a
result of PSA testing.
· The USPSTF panel itself graded the studies used in drawing their conclusions as
either “good, fair or poor” regarding their underlying scientific methods. The
PLCO and ERSPC studies each graded “fair.” Of the 20 studies examined
regarding the benefits of screening for prostate cancer, one was graded “good,” 18
were graded “fair,” and one graded “poor.”
· The USPSTF bases their objections not on the risks of screening,
which are negligible, but the risks of diagnosis and treatment of cancer. This
is a scientific bait and switch of the worst order. Screening is not diagnosis,
nor is it treatment; it is a method to provide patients and their doctors with
information that is then used to determine the appropriateness of further
evaluation and/or treatment.
The task force’s recommendation is not binding, but as a government funded
initiative, the concern is that Medicare will stop paying for screening and, if so,
private insurance companies will follow suit. Every man has a right to make his
own decision about screening after reviewing the potential risks and benefits with
his own doctor. We cannot allow an unaccountable government entity to deny
patients access to tests that saves the lives of thousands of Americans every year.
The final recommendation by the USPSTF is a one size fits all philosophy that states that patients cannot be trusted to make informed decisions on their own. This same task force suggested mammograms were unnecessary for women ages 40 to 49 and has also recommended against teaching women breast self exams, both of which were retracted after massive public outcry. The USPSTF’s recommendation risks undoing 20 years of progress in patient education.
We, as practicing Urologists, have seen that early detection leads to better outcomes for
our patients. Ask any man whose life has been saved as a result of taking the PSA test.
They'll tell you early detection of prostate cancer is the real difference between life and
death. They’ll tell you the PSA test identifies cancer early, before it has spread.
We believe the decision on how best to test and treat for prostate cancer must be made
between a man and his doctor, not from a government funded panel that doesn’t even
include experts in the disease.

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