A Perfect Storm: PSA Screening is Imperfect But Not Failed
The morning after the final USPSTF recommendation against widespread PSA screening leaves me believing that many have missed their mark and their efforts could have been better directed.
The debate over PSA screening began to simmer and quickly rose to a boiling point about three years ago. Opponents pointed to the problem of overtreatment (according to scholars at Johns Hopkins, overtreatment costs more than $1 billion annually in the U.S.). Proponents looked to the reduced number of prostate deaths as a mark in favor of screening. Studies from both sides of the Atlantic were both complex and provided differing data, making them easy fodder for campaign positions. In short, all the makings of a perfect storm for the debate were in place.
What was missing in the equation was general acceptance that there is a middle ground. One can find it by acknowledging that while PSA screening is imperfect, it is not a failed test. While it is not cancer-specific, it is not a failed test.
In my completely personal opinion, all parties in the debate, including the United States Preventive Services Task Force, would have been better served by launching a nationwide men’s health campaign for patients and clinicians, outlining the pros and cons of both screening and of various treatment options so patients could make informed decisions regarding their personal healthcare. This should have been coupled with an urgent call for research funding that is making rapid progress for better, prostate cancer-specific biomarkers. Just one example, out of the University of Michigan, is a simple urine test (looking TMPRSS2:ERG gene fusion and PCA3 DNA that are expressed at high levels in 95 percent of prostate cancers) that has the potential to eliminate thousands of unnecessary biopsies and more accurately direct those who can benefit from proactive surveillance rather than aggressive treatment.
But guess what? Even with this urine test, PSA screening would still have an important preliminary role in an informed diagnostic and treatment decision process…
One fellow patient aptly captured what I believe is the feeling of many patients when he posted the following on the Men’s Prostate Cancer Support Group page of Facebook (an invitation-only private forum for men dealing with prostate cancer and treatment): ”Enough of the nanny state. We are big boys. Give us our PSA and we can decide if we want a biopsy or further treatment knowing the risks involved. But let us decide and give us the only tool we currently have.”
Lancet Oncology, the prestigious medical journal, reports that 84 percent of women in the United States are alive at least five years after receiving a diagnosis of breast cancer. Only 70 percent of British women survive that long. Further, 92 percent of American men with prostate cancer survive for at least five years, compared to 51 percent of Britons. In Britain, PSA screening is less utilized and prostate cancer is often diagnosed in more advanced stages.
The good news that needs to be reiterated is that the Department of Health and Human Services has already stated that Medicare will continue to reimburse for PSA screening. Private insurers, some reinforced by State mandates, should also continue reimbursing for this simple blood test.
Already, many groups are rallying to reach out to their Congressional representatives, asking them to have the USPSTF recommendation reversed. How much more time and effort will that take? How much more confusion will be generated?
From the standpoint of one who believes that his advanced disease was caught in time by the PSA, I also understand and sympathize with those many men who might have been overtreated in their rush to rid themselves of what might have been a non-life-threatening variety of this disease. Thus, any further discussion on reversing the final decision of the USPSTF is futile unless it calls for a clear and concise education campaign on what the PSA is and isn’t capable of doing, the pros and cons of treatments AND and urgent call for funding new biomarkers as fast as our researchers can validate and commercialize them.
Only with better biomarkers can we put this issue to rest. Only then can we overtreat less and cure more.