The James Buchanan Brady Urological Institute
   Misfire: Bad Advice from a Government Task Force
                 Volume 9, Winter 2013

For nearly 20 years, in this publication and its predecessor, Prostate Cancer Update, we have given you "all the news that's fit to print" – everything we have been learning about prostate cancer, our clinical advancements and scientific discoveries. It has always been, and remains, cutting-edge information (like Bill Isaacs' exciting discovery of a major prostate cancer gene – see story). And the best thing for all of us here at the Brady Urological Institute is that the news has just gotten better over time.

With one exception. Recently, something happened that is not good news; in fact, it has the potential to be disastrous. In a move that has stunned and outraged those in the medical community dedicating ourselves to treating and curing prostate cancer, The United States Preventive Services Task Force (USPST F) has recommended against PSA screening for prostate cancer. Its message to men: "Don't worry about screening. If you're diagnosed with prostate cancer, don't worry about it. You probably won't die of it."

This is simply not true. If you're a patient here at the Brady, you probably already realize this; but we'll explain more in a moment. First, you need to know that the panel is made up of "independent scientists who are better able to objectively evaluate the literature without bias." No urologists or other prostate cancer specialists were invited to participate.

According to the panel, "healthy" men don't need PSA screening. We know that this is a bad idea, because we have already been there and done that. We lived through it, and for most men diagnosed with prostate cancer, the picture was not pretty. In effect, this decision sets the clock back to before the 1990s, when "healthy" men were diagnosed with cancer that was palpable – because there was no blood test to help detect it. Too often, these men were diagnosed when their cancer was too late to cure. (For a look at the numbers and the impact of the "nerve-sparing" radical prostatectomy on cancer control after PSA screening began, see illustrations)

Knowing the outcome of cancer in the days before PSA screening prompts a question that looms like the proverbial elephant in the room: Is this panel's recommendation about progress, or about saving money?

Prostate Cancer 101
Some very basic facts about this disease: Prostate cancer is the most common cancer in American men and the second most common cause of cancer death. Because the cancer begins on the prostate's outer edges, it produces no symptoms until it is far advanced and too late to cure. It can be diagnosed with a rectal exam, but it has to have achieved a size big enough to be felt by a doctor – and often, by the time the cancer has grown this much, it has also spread past the confines of the prostate. Yet years before this happens – in a man who is still outwardly "healthy" – PSA is silently trumpeting the danger. Because of pioneering work led by Johns Hopkins, we know how to read PSA . We know at what level it should be, in men of every age; we know when its rise is fast enough to warrant a biopsy, and by looking at components of PSA , when its number is most likely due to benign enlargement. PSA is not perfect, but it has saved tens of thousands of lives. And thanks to PSA testing, we have proven that early diagnosis is everything. It is the cornerstone that has dramatically reduced death and suffering.

In 1991, before PSA testing became widespread, 20 percent of men with a new diagnosis of prostate cancer had a tumor that had already spread to their bone. Today that number is less than 4 percent. It's hard to imagine now, but in 1991, one out of five men had metastases. Today, it's one out of 25. The effect on deaths is equally dramatic.

Between 1994 and 2004, prostate cancer deaths plummeted 40 percent – more than for any other cancer in men or women. But what would have happened if PSA testing and effective treatment had not come along? Using the age-adjusted death rate from 1990 of 39.2 prostate cancer deaths per 100,000 men and applying it to 2007, there would have been 59,000 deaths. Instead, because the death rate fell to 23.5, there were 35,000 deaths. Thus, 24,000 fewer men died from prostate cancer in 2007 alone. Because advances in treatment have also played a role, scientists from the National Cancer Institute estimate that 40 to 70 percent of this reduction is the direct result of screening.

Turning a Blind Eye to Lives Saved
Unfortunately, the USPST F never mentions these figures, and makes no attempt to reconcile them with its recommendations. The scientists did use large, uncontrolled observations to look at the complications of surgery – but not at the number of lives saved since PSA testing was introduced in the United States in the early 1990s.

Also, the USPST F recommendations are based on two trials with 10 years of followup – even though it is widely accepted that men with a lifespan of fewer than 10 years should not be screened or treated. So what should have been their conclusions? That men with a lifespan of less than 10 years should not undergo PSA screening. However, screening has been definitively shown to save lives for younger, healthier men.

The USPST F ignores or fails to recognize that without PSA testing, a man will not know that he has the disease until he has symptoms, at which time the cancer is too far advanced to cure. In the absence of mammography, at least a women can palpate her own breast to search for a lump. If the Task Force is trying to fix the downstream consequences of over-diagnosis and overtreatment, why not encourage funding agencies to enforce the National Comprehensive Cancer Network (NCCN) Guidelines for diagnosis and treatment? Instead, it chose to deny healthy young men with asymptomatic, potentially deadly cancer the chance of cure. This is like removing all the scalpels in a hospital to prevent unnecessary surgery. If this recommendation is widely adopted by physicians and insurance companies, in the next five years we should expect to see 65-year old men arriving for their first PSA (in 1997 Congress mandated Medicare to pay for PSA testing) with advanced disease. Indeed, a recent study predicted that as a result of PSA testing there are 17,000 fewer men per year diagnosed with metastatic disease today, compared to the pre-PSA era.

On a more encouraging note, the American Society of Clinical Oncology has rejected the USPST F recommendation. Instead, it has made the sensible decision to discourage PSA screening in men with a life expectancy of less than 10 years, but to advise men who are expected to live longer than 10 years to discuss the benefits and harms with their physician.

 The Bottom Line

PSA screening has saved tens of thousands of lives. To abandon it, in effect, is turning the clock back to the early 1990s, when 20 percent of men were diagnosed with cancer already in their bones, and one out of five men had metastases. There is potential for disaster if men stop getting PSA screening. The American Society of Clinical Oncology has rejected this recommendation. Instead, it has made the sensible decision to discourage PSA screening in men with a life expectancy of less than 10 years, but to advise men who are expected to live longer than 10 years to discuss the benefits and harms with their physician.

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