# Final advice: Panel against routine prostate test

By LAURAN NEERGAARD AP Medical Writer Published: May 23, 2012 at 9:04 AM PDT

WASHINGTON (AP) — Healthy men shouldn’t get routine prostate cancer screenings, says updated advice from a government panel that found the PSA blood tests do more harm than good.

Despite strenuous protests from urologists, the U.S. Preventive Services Task Force is sticking by a contentious proposal it made last fall. A final guideline published Monday says there’s little if any evidence that PSA testing saves lives — while too many men suffer impotence, incontinence, heart attacks, occasionally even death from treatment of tiny tumors that never would have killed them.

The guideline isn’t a mandate. The task force stresses that men who want a PSA test still can get one, but only after the doctor explains the uncertainties. That’s in part because the panel found PSA testing hasn’t been studied adequately in black men and those with prostate cancer in the family, who are at highest risk of the disease.

The Obama administration said Monday that Medicare will continue to pay for PSA screenings, a simple blood test. Other insurers tend to follow Medicare’s lead.

“This is important information for the public and men to have, and they should talk with their doctors about the risks and benefits of prostate cancer screening and make the decision that’s best for them,” said Mark Weber, a spokesman for the Department of Health and Human Services.

The task force advice goes a step further than major health groups including the American Cancer Society, which has long urged that men decide the issue for themselves after being told of PSA’s pros and cons. But it’s not likely to end an annual ritual for many men 50 and older. After all, the same task force has long urged men over 75 to skip PSA screening, and research suggests almost half of them still get tested.

The controversy will end only with development of better tests — to finally tell which men’s tumors really will threaten their lives, and who will die with prostate cancer rather than from it, said Dr. Virginia Moyer of the Baylor College of Medicine, who heads the task force.

“We have been told for decades to be terrified of cancer and that the only hope is early detection and treatment,” she said. The reality: “You don’t need to detect all cancers.”

“We don’t want this to be the answer,” Moyer added. “We want to screen for the ones that are going to be aggressive, manage those early — and leave everyone else alone.”

In an editorial published with the guideline in Annals of Internal Medicine, some urologists argue the panel underestimated PSA’s value and overestimated its harms.

“What PSA screening offers the men is a substantial opportunity to avoid dying a particularly unpleasant death from prostate cancer,” said editorial co-author Dr. William Catalona of Northwestern University, who pioneered the testing.

He spoke Monday from a meeting of the American Urological Association, where doctors debated the guideline’s impact. The urology association advises that men be informed of the potential risks and benefits before screening.

But Dr. Otis Brawley, the American Cancer Society’s chief medical officer, welcomed the task force’s recommendation. He hoped it would help deter mass screenings, where men are given free PSAs at shopping malls and sports arenas without being told of the controversy, screenings that Brawley calls big business when health centers profit from the follow-up care.

“The question is, are we actually curing anybody who needs to be cured right now?” Brawley asked.

Too much PSA, or prostate-specific antigen, in the blood only sometimes signals prostate cancer is brewing. It also can mean a benign enlarged prostate or an infection. Only a biopsy can tell. Most men will get prostate cancer if they live long enough. Some 240,000 U.S. men a year are diagnosed with it, most with slow-growing tumors that carry a very low risk of morphing into the kind that can kill.

To evaluate whether routine screening saves lives, the task force analyzed previous research, focusing in particular on two huge studies in the U.S. and Europe. The panel’s conclusion:

—Without screening, about 5 in every 1,000 men die of prostate cancer over 10 years. The European study found PSA testing might prevent one of those deaths, while the U.S. study found no difference.

—Of every 1,000 men screened, two will have a heart attack or stroke from resulting cancer treatment, and 30 to 40 will experience treatment-caused impotence or incontinence.

—Of every 3,000 men screened, one will die from complications of surgery.

Both the U.S. and European studies have flaws, and task force critics argue over which are most believable. And while U.S. death rates from prostate cancer have dropped over 20 years, the cancer society’s Brawley says the drop began before PSA testing became widespread. Moreover, the risk of death is the same in Europe and the U.S. even though many more American men are screened, diagnosed and treated, he said.

“We need to do a better job of using PSA wisely,” said Dr. Scott Eggener, a University of Chicago prostate cancer specialist who was disappointed the task force went so far. “Most people would agree that a well-informed, young, healthy patient should have the opportunity to talk about it with their physician.”

But he’s studying a way beyond the screen-or-not controversy: Having men with small, low-risk tumors postpone treatment in favor of “active surveillance,” keeping close watch on their tumors and treating only if they grow. More than 100,000 men a year are candidates, concluded a recent meeting at the National Institutes of Health.

That approach could “maximize the benefits of screening,” Eggener said.


Government task force discourages routine testing for prostate cancer

Brian Vastag, Published: May 22

Men should no longer receive a routine blood test to check for prostate cancer because the test does more harm than good, a top-level government task force has concluded in a final recommendation that immediately became controversial.The recommendation from the U.S. Preventive Services Task Force runs counter to two decades of medical practice in which many primary-care physicians give the prostate-specific antigen (PSA) test to healthy middle-aged men.

But after reviewing the available scientific evidence, the task force concluded that such testing will help save the life of just one in 1,000 men. At the same time, the test steers many more men who would never die of prostate cancer toward unnecessary surgery, radiation and chemotherapy, the panel concluded.

For every man whose life is saved by PSA testing, another one will develop a dangerous blood clot, two will have heart attacks, and 40 will become impotent or incontinent because of unnecessary treatment, the task force said in a statement Monday.Many middle-aged men regularly get the PSA test. But for years, some experts have questioned whether such screening saves lives. Monday’s statement finalizes a draft recommendation made by the task force last fall.While not mandates, the group’s statements have widespread impact, especially on private insurers and Medicare.The recommendation raises the question of whether a test deeply embedded in the medical landscape can be pulled back.“It’s a tough message,” said Virginia Moyer, chairman of the task force and a professor of pediatrics at the Baylor College of Medicine in Houston. “Nothing would have made us happier than to have found that [routine PSA screening] really works.”Moyer added that men who have urinary symptoms — such as pain or difficulty urinating — may still benefit from PSA testing.

“Our recommendation is not a recommendation to tell the patient to shut up and go away if they ask about” PSA testing, Moyer said. “Our recommendation is that it not be routinely offered.”

Insurers react

Officials at two large insurers said the companies are unlikely to cease coverage in the near future. Lori McLaughlin, a spokeswoman for WellPoint, said the company “considers continued screening for prostate cancer as medically necessary for men between the ages of 50 and 75” but will continue to review the evidence.

Tammy Arnold, a spokeswoman for Aetna, which considers PSA screening a medically necessary preventive service for men age 40 and older, said officials there will review their policies.

Specialists who diagnose and treat prostate cancer reacted swiftly. The American Urological Association said it was “outraged” by the recommendation. “Men who are in good health and have more than a 10-15 year life expectancy should have the choice to be tested and not discouraged from doing so,” the group said in a statement.

The Large Urology Group Practice Association, which represents 1,800 urologists, issued a statement saying it was “appalled” and called the recommendation “irresponsible and inexplicable.”

Any man worried about prostate cancer should discuss the risks and benefits with his physician, said Moyer, a message that the American Cancer Society has been pushing since 1997.Alexander Chester, a primary-care physician in the District, said he explains the risks of unnecessary injury before offering PSA tests. “But half the people still want it,” he said. “It will take a long time to get it out of the popular culture.”
In the District, which has the highest incidence and highest death rate of prostate cancer in the country, some doctors said they will continue to rely on the test, especially when screening black men, who have higher rates of prostate cancer than white men.
“We will recommend it in the black population because of the amount of cases that we see that are requiring treatment and not active surveillance,” said Oscar Streeter, a radiation oncologist at Howard University.The reaction from physicians who say prostate cancer is overdiagnosed was positive.“This recommendation is a huge win for men,” said Georgetown University’s Kenneth W. Lin, who has studied PSA screening. “Can you imagine performing mammograms regularly on women without first collecting scientific evidence that they save lives?”Otis Brawley, chief medical officer of the American Cancer Society, commended the task force for “taking a really hard line here.”Brawley said that PSA testing has become “big, big money,” with testing companies, physicians and hospitals all profiting.Other conditions

PSA tests do not directly detect cancer — they detect a protein made by the prostate. Conditions other than cancer, including benign growth of the prostate, can raise PSA readings, leading to painful biopsies and other tests.

The Food and Drug Administration has never approved PSA testing for the general population. Instead, the agency in 1986 allowed the test to be used to evaluate men who have urinary symptoms. But physicians are free to use the test however they choose, and a huge industry quickly sprang up that promoted the tests to healthy men.

Until recently, no large, high-quality study had looked at whether widespread, routine PSA testing saved lives. In 2009, that changed when results from two studies, in the United States and Europe, generally found that it did not. In the European study, there was some hint of a benefit in two of seven countries, in men 55 to 69, Moyer said.

Brawley said PSA testing now joins the ranks of other medical procedures that proved to be ineffective after widespread adoption. In the 1960s, chest X-rays were used to diagnose lung cancer, but a large study in the 1970s found they led to overdiagnosis. In the 1990s, many women with breast cancer were offered an extreme treatment — bone marrow transplants — before a study found that the treatments were not saving lives.

“Medicine has made all these mistakes, and in prostate cancer this has been a very lucrative business for the last 20 years,” Brawley said.

Prostate cancer is the second most common cancer in men, after skin cancer. About 242,000 cases are diagnosed each year in the United States, with about 28,170 men dying of the disease. Most cases do not lead to death, because many of the cancers are slow-growing and not life threatening.The 16-member task force, made up of independent experts, is organized by the Department of Health and Human Services to assess preventive medical care. The group’s influence was enhanced by the 2010 federal health-care law, which will base some of its requirements for coverage on the group’s ratings.

Staff writers N.C. Aizenman and Lena H. Sun contributed to this report.


What is the chance for a diagnosis of prostate cancer:

For a man in his 40s –
1 in 1000
For a man in his 50s –
12 in 1000
For a man in his 60s –
45 in 1000
For a man in his 70s –
80 in 1000
  • Each year in Australia, close to 3,300 men die of prostate cancer – equal to the number of women who die from breast cancer annually. Around 20,000 new cases are diagnosed in Australia every year.
  • Each day about 32 men learn news that they have prostate cancer – tragically one man every three hours will lose his battle against this insidious disease
  • One in 9 men in Australia will develop prostate cancer in their lifetime
  • Prostate cancer is the most common cancer in Australian men and is the second most common cause of cancer deaths in men
  • As many men die from prostate cancer as women die from breast cancer but… a national survey by PCFA in 2002 showed that while 78% of women felt well informed about breast cancer – only 52% of men felt informed about prostate cancer
  • The chance of developing prostate cancer increases:
    • as men get older.
    • if there is a family history of prostate cancer eg a man with a father or brother diagnosed with prostate cancer
  • Early, curable prostate cancer may not have symptoms. While younger men are less likely to be diagnosed with it, they are more likely to die prematurely from it
  • Simple testing by a GP can indicate prostate cancer
  • Early detection can be achieved with PSA (Prostate Specific Antigen) blood test or DRE (Digital Rectal Examination) testing. Our research in 2002 shows that only 10% of men surveyed between the ages of 50 and 70 had taken these tests in the previous year.
  • Some groups are at greater risk of prostate cancer
  • … for example, for every 100 men who dies of prostate cancer in a metropolitan area of Australia (such as Melbourne or Sydney) 121 men will die in rural Australia. Various factors may include lack of awareness and education about prostate cancer, distance from testing and treatment, poor GP awareness and limited access to specialists (such as urologists)
  • The Vietnam Veterans Association of Australia states that veterans have a 53% higher mortality rate from prostate cancer than the average population
  • A recently published international study showed that firefighters have a 28% higher risk of prostate cancer

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