Prostate cancer continues to remain the leading cause of cancer in men in the United States. Over 30 thousand men are estimated to die of prostate cancer this year alone. Also, for reasons that are not completely understood, African-American men are 60% more likely to be diagnosed with prostate cancer and 2.5 times likely to die of the disease.
The PSA test is a blood test that measures prostate-specific antigen (PSA), a protein produced by the prostate gland. An increase in the PSA level is often the only sign of early prostate cancer. The PSA test is also valuable in following patients after treatment.
A recent report published in The Annals of Internal Medicine by a U.S. Preventative Services Task Force Committee stated that PSA testing should no longer be performed routinely on men in the United States. The task force came to this decision based on studies performed in the United States and Europe suggesting that prostate cancer screening does not appear to improve survival in patients with this disease. The two principal studies quoted in the report are the prostate, lung, colon, and ovarian screening study (PLCO) and the European randomized prostate cancer screening study. Both studies compared men who were screened to those who were not screened over a 7-10 year period. The European study actually revealed an improvement in survival whereas the American study did not, thus reporting conflicting results.
One of the many concerns raised by prostate cancer experts and advocates is related to the fact that most of the studies sited in this report had a notable lack of representation of African-American men. Additionally, in the absence of PSA-based early detection strategies, the incidence of advanced disease would certainly increase. In the pre-PSA era, most men who presented with prostate cancer were symptomatic at diagnosis and had evidence of metastatic disease (in other words the cancer had already spread). Although the overall death rates associated with prostate cancer have begun to decline, African-American men still carry a disproportionately higher death rate. Those under the age of 60 are 4 times more likely to have metastatic disease at diagnosis. The report minimizes the impact of metastatic disease stating that it is unlikely to result in death. However, metastatic disease can have tremendous impact on quality of life including chronic pain, pathologic fractures, paralysis, bleeding, and other tragic consequences.
It is also striking that none of the task force committee members have specific clinical expertise in treating prostate cancer. This attempt to apply a broad-sweeping policy to a very complex disease affecting populations disproportionately is very short sighted. The bottom line is that fewer men are dying of prostate cancer and it is very likely that early detection has played a role in this outcome. Although the PSA test cannot take all the credit, it has been the cornerstone for early detection over the last 2 decades. There is ongoing research to find better screening strategies. However, until these tests have been confirmed, PSA is an important part of early detection and should not be blatantly discarded, especially as it applies to high-risk populations such as African-American men. Any man interested in having a PSA test should have meaningful dialog with his health-care provider to understand the details of the test, it’s value, and possible shortcomings. That should have been the message from the report. I hope that health-care providers involved in prostate cancer care will respond strongly to these recent recommendations.
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