USPSTF adopts my reasoning on PSA screening for prostate cancer

April 13, 2017
Which way on PSA?

I oppose over-testing and over-treatment, so I really had to think hard five years ago when I turned 45 and my doctor offered PSA screening for prostate caner. The US Preventive Services Task Force (USPSTF) had just come out against PSA screening, concluding that the harms outweighed the benefits.

Nonetheless (Why I decided to get a PSA screening test for prostate cancer), I did go forward. As I wrote:

I know that PSA is a very imperfect indicator. I definitely want to avoid the stress and possible discomfort of having a biopsy. I’m worried about false positive and false negative biopsy results. And I don’t relish the significant potential for incontinence, impotence, or bowel problems from treatment.

But at this stage of my life I am willing to accept a significant risk of morbidity in exchange for a small reduction in mortality risk, which is my impression of what my choice to have the PSA test means. In 10 or 20 years I probably won’t feel that way. And I hope there will be better detection, follow-up and treatment options by then.

I’m also confident in my ability to make informed choices with my physicians along the way. The PSA test itself was done as part of routine blood work and there was no additional risk from that. My doctor and I agreed that if the PSA is elevated we’ll discuss what to do next. At that stage I’ll also have the chance to do more research and get more opinions if necessary. I’m not automatically going to get into a cascade of follow-up and treatment.

Now the USPSTF appears to be coming around to my way of thinking. In particular, they note that more men are choosing “active surveillance,” i.e., keeping a close watch rather than jumping straight to aggressive treatment.

The choice about whether to undergo PSA testing and what to do once results are in is a great opportunity for shared decision making. And this is what should be encourage.

By healthcare business consultant David E. Williams, president of Health Business Group.

4 thoughts on “USPSTF adopts my reasoning on PSA screening for prostate cancer”

  1. The popularity of multiparametric MRI for the prostate, meanwhile, is skyrocketing, and this is largely due to its ability to specifically avoid many biopsies in cases of elevated PSA without other suspicion for cancer (on physical exam, family history, certain high risk groups, etc). mpMRI of the prostate is an interesting beast in that it’s supposed weakness (not very good at catching low-grade cancers) is actually its strength (avoid biopsy for cases unlikely to be high-grade cancer worth treating).

    In other words, your “significant risk of morbidity” can somewhat be mitigated with a 20-30 minute trip into the magnet. It is also a nice example of when a high-ish cost, advanced imaging test will likely reduce future higher cost and higher morbidity surgical procedures.

    I have no idea whether the USPSTF considered the popularity and increased availability of MRI when revising their stance regarding active surveillance.

    1. “not very good at catching low-grade cancers”

      Urologists will not accept a technique that does not detect cancers that they might want to treat. MRI can only lead to an increase in detected (and treated) cancers, the vast majority of which would never cause prostate cancer mortality or do not benefit from much earlier treatment.

  2. “But at this stage of my life I am willing to accept a significant risk of morbidity in exchange for a small reduction in mortality risk”

    But you just don’t know that there is even a small reduction in mortality risk. Not even a small reduction in prostate cancer specific mortality risk. Achieving an inconsistent disease specific reduction in just 2 countries out of 7 in Europe and nowhere else either is hardly a reliable basis for expecting there is even a small reduction in disease specific mortality risk. And that’s before even considering overall mortality which is a necessity for proof of benefit:

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