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.

Before the storm, the middle ground was missed.

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.

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22 Responses to “A Perfect Storm: PSA Screening is Imperfect But Not Failed”

  1. Great Post!! The PSA Test saved my life! If I would have followed the guidelines of waiting to get testing my results would be much worse. Diagnosed at 36 and was already Stage T2c! Tough to support the American Cancer Society as well with their views of testing now as well, where before their motto was for preventive testing which has changed…

  2. I agree with you on, “there is the middle ground.” Why does the debate have to be an all or nothing thing? There will always be over treatment and under treatment.

    Until a better screen test is available why not let a man decide what is best for him. Finding the cancer in its earliest stages has always made the most sense to me.

  3. Today’s media brouhaha over the USPSTF announcement misses the point that you raise here, Dan: PSA testing should be part of a more comprehensive process that includes DREs and intelligent conversation with knowledgeable docs. The underlying USPSTF presumption seems to be that both men and their docs are so ignorant or adverse to a serious conversation before taking the next step leading inevitably to over-treatment that it would be better to deprive the conversation of useful data. One senses a nanny state mentality at work here.

    If nothing else, we are at least raising PCa awareness in the public consciousness, and perhaps there is greater hope for what you call for: increased education re PCa and PSA pros and cons, as well as urgent calls for funding the biomarkers that will reliably distinguish between indolent and aggressive forms of this disease.

  4. Very well put, Dan.

    It appears the task force thinks we are too stupid to make an informed decision and so their solution is to withhold the information.

    As I have learned, there is a lot to consider when presented with a PC diagnosis. It is rarely a simple choice.

    Much more education is needed so that men and their loved ones can make good decisions with their PSA results.

    I agree with you wholeheartedly that the solution is to provide this education, not to withhold the test and its results.

  5. “(according to scholars at Johns Hopkins, overtreatment costs more than $1 million annually in the U.S”

    In the 2000 census there were 138 million men in the US …..how many men has PSA screening saved? 1 million bucks a year seems reasonable. Early screening detected my cancer at age 45. If the GP had followed guidelines he wouldn’t have even run PSA until age 50.

  6. Dan,
    You know me and my story. All I can say is that a routine PSA test at the age of 50 saved me. My cancer was found at the T1c stage. I will soon be 2 years cancer free so what is a $1000000 bucks to save us guys. How many millions go the screening for breast cancer????
    Again the old debate….what you can’t see doesn’t get the attention it deserves. ( you can’t see a prostate but you can see a breast ). Such a shame……but that is another blog.
    Thanks for keeping us informed. I “believe” the message will get to the right people soon.

  7. If this were breast cancer, would we be having this discussion? I don’t know of many men or women whose screening has identified a high risk tumor who would rather not have known.

  8. Great post, Dan. I too sympathize with men who have undergone needless aggressive therapy. I have a cousin in his sixties who wishes he had not been screened. On the other hand, I got my first PSA at age 57, and it came back over 950. You bet I wish I had started getting my PSA’s when I was 45. And I have to add that I am pretty cynical about experts who point to all the money that can be saved by ending PSA screening.

  9. Can I tactfully point out that the cost of over-treatment in the field of PCa is more like a billion? The ‘million’ has to be a typo and as far as medical costs go is just a drop in the ocean.

  10. If prostate cancer is as prevalent in men as we are told that it is, then I believe that PSA tests should be administered even earlier than at age 45, maybe as early as age 25, to establish a person’s baseline numbers. The baseline could provide a better understanding “per individual”of the meaning of those numbers and the course that they take over the years.

    That, and of course, the DRE, etc. tests, which can begin a little later. Not to forget Dan’s call for more research to find a better way to discover the presence and voracity PC.

  11. Without PSA I would have had Frank Zappa’s destiny. At age 53, my PSA rose in less than two years from normal value to 23. Two extended biopsies (36 shots in total), in two different hospitals, couldn’t find anything, and even PCA3 was very low. But I believed in PSA, and its exponential growth worried me. So during last summer holidays I went to Holland (Nijmegen), to prof. Barentsz – a wonderful man and doctor – and his MRI guided biopsy. 5 targetted shots only, 5 centers: all Gleason 8. Urologists will probably call it a PEAT, prostate evasive anterior tumor.
    I had robotic prostatectomy in september, but the pathologist report was bad: T3a N1. So I joined the Stage 4 club. Radiotherapy in january and february of this year, and I’m on ADT since last november. Hot flashes, fatigue, etc etc.
    But if I had trusted the biopsies, and not PSA, I’d probably have now cancer in the bones.
    Long life PSA, and MRI!!
    Francesco

  12. The PSA test is about information NOT treatment – this is where the USPSTF as well as others have missed the point. Their efforts should be focused on educating both the medical profession as well as men how to interpret the information and respond to it in an intelligent and responsible manner.

    Like most men diagnosed with high-risk disease I find it irresponsible to discount the PSA test as ‘causing’ over-treatment; it has saved our futures and will continue to save 30,000 – 40,000 men annually if employed widely. Over treatment is down to poor decision making as much as an imprecise test.

  13. Dan,
    My idiot GP didn’t believe in PSA tests as showing “too many false positives” when I repeatedly asked him about then since I was 50. I finally asked for one myself, without his knowledge, at age 56 and discovered a PSA of 510 and stage 4 cancer. Thank you very much. PSA testing may yield challenging and troubling facts, but at least you have a choice, even if it to ignore the test data. Earlier establishment of baseline PSA is reasonable and until there is another alternative it is the best game in town for early warning. I’d have done ten biopsies to have been presented the information needed to make a life-saving decision in a timely manner. How many of the panel have or are involved with people with cancer? I’d wager few if any. How close are their ties to the insurance industry?
    PSA testing…..hell yeah!
    Bill W.

  14. “What the U.S. Preventive Services Task Force Missed in Its Prostate Cancer Screening Recommendation,” an authoritative refutation, published in Annals of Internal Medicine on May 21, 2012, can be reviewed at the following link:http://www.annals.org/content/early/2012/05/21/0003-4819-157-2-201207170-00463.full
    Jim Duncan

  15. Is Your “Check Engine” Light On?

    A government task force recently proclaimed that the Prostate Scientific Antigen (PSA) test need not be administered to detect cancer. The report indicates that the results of surgery can result in incontinence, sexual dysfunction, heart problems and even death. Men for years have had this test and for many it has resulted in a new lease on life when early stage cancer is detected and cured. Odds are that one man in six will develop prostate cancer – not very good odds! While it is a slow advancing cancer, men still die of prostate cancer.

    For years men have had a PSA test usually at the time of an annual physical. If the readings are within an acceptable range no action is taken. However, if the readings begin to rise on each subsequent exam, further testing and perhaps a biopsy may be warranted. The results of the PSA test remind me of the “check engine” light on our cars. When the light appears on our dashboard we have no idea what it means so we take the car to an expert who performs a series of diagnostic tests to pinpoint the problem. Something similar occurs with the PSA test. Until we submit to further testing we have no idea what the increased readings on our PSA signify.

    Several years ago my PSA test indicated a slight increase in the numbers. As a result, my doctor suggested that I have some further tests. Those tests revealed that two biopsies came back positive for cancer. As such, after researching the various options for over two months, I opted for robotic surgery at Henry Ford Hospital in Detroit. Physicians there are the pioneers in this type of surgery as men come from all over the world for the operation – one came as far away as Antarctica! The results of my surgery indicated that my Gleason score (a gauge on how fast the cancer might spread) was a six meaning that I had experienced the beginning stages of cancer. The surgery was painless – I went home the next day – and in less than a month I resumed my daily five mile runs. Since my surgery which has now been four years, all systems are “go” which means I have returned to my normal lifestyle. If you are wondering how my marital responsibilities are progressing feel free to ask my spouse of 49 years. I think she will tell you, as they say in the space program, that all systems are “A-Okay” meaning that launch and landing continue to be very successful!

    June 2 will be the fourth anniversary of my surgery and my PSA test continues to be 0.0! On that date I will be having lunch with my surgeon, Dr. James Peabody and my nurse Andrea Simone. Yes, we celebrate this anniversary every year. As such, I would suggest that just as us guys investigate our “check engine” light on our cars, we should continue to “check our prostate numbers”. We all want smooth running cars and who doesn’t want a smooth running body! Get the test! Your body engine is similar to the car engine – no one wants to experience a “recall”!

    Bill Kalmar
    Lake Orient, Michigan

  16. Interesting that the task force did not have a Urologist or Oncologist on it. I am thankful everyday for the PSA test because without it, I would have had no idea that I had an agressive prostate cancer. If not discovered early, as mine was, I probably would not be here today.

    Statistically, I understand their point but you can mold statistics anyway you want. It would be like saying that traffic accidents are caused by eating green beans because most people who have an accident eat green beans.

    Leave the decision up to us and our physicians
    Ed Kozlowski
    Audubon, NJ

  17. There has to be a common grounds agreement about the importance of the PSA. My personal experience is in support of early detection. Nine years ago at the age of 43 my GP decided for me to have a PSA to establish a baseline because I am African-American. I had no family history or symptoms. The PSA came back elevated. I was referred to an Urologist who believed as I do in being aggresive with treatments. Biopsies came back with a Gleason score of 9. After Prostatectomy, radiation and now being on Lupron (what a long strange trip it’s been) I enjoy life and it’s challenges and rewards.
    I wonder at times how different things would be If my Physician had the same attitude or was hamstrung by Insurance companies to not presribe a PSA. Would I still be alive today? Or the cancer spread to other organs or my bones?
    Cancer not only affects patients, but family and friends. My daughter and I celebrate every June 17, the day of my surgery with Pizza and Ice Cream, it doesnt matter where in the world we are. Because I craved it when i came out of surgery. She is a great part of my strength. Speak to the families that have to support and care for cancer patients. They give so much more than money, It takes a great toll on any support group to get someone through any cancer treatment. I am sure my family would say that they wished i was diagnosed earlier.
    This is not a simple matter of yes or no. I understand there are financial condideration about overuse, but “how many men’s live can 1 billion dollars buy.”

    • Luke,

      Thank you for sharing your compelling story. I wish you abundant health many more years of ice cream and pizza celebrations!

      All the best,
      Dan

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  1. A zillion "new" protons fight my prostate cancer » Blog Archives » My Take on The PSA Test & PC Treatments - June 27, 2012

    [...] Anyhow, these and other thoughts ran through my mind when I read the great article by the VP of the Prostare Cancer Foundation, Dan Zenka, in his blog, MyNewYorkMinute.org, entitled:  A Perfect Storm: PSA Screening is Imperfect But Not Failed. [...]