PCF responds to USPSTF recommendation about PSA screening


The “New” Prostate Cancer InfoLink has replicated below, in its entirety, a media release issued early this morning by the Prostate Cancer Foundation. We believe that this is precisely the correct response to the new USPSTF recommendation: acknowledgement of the realities of the USPSTF’s factually accurate recommendation and the recognition by the USPSTF that PSA testing is not going to go away in the immediate future … nor should it!

PCF RESPONDS TO U.S. PREVENTIVE SERVICES TASK FORCE RECOMMENDATION ON PSA SCREENING

While needing better guidelines, the PSA test still plays an important role in detecting early prostate cancer in informed patients

LOS ANGELES/October 10, 2010 — The mission of the Prostate Cancer Foundation (PCF) is ending suffering and death from prostate cancer through research. PCF received a copy of the U.S. Preventive Services Take Force report late Friday. Today, PCF issued its analysis of the heavily-debated recommendations of the U.S. Preventive Services Take Force regarding PSA screening in healthy men.

The Prostate Cancer Foundation:

  • Supports continued routine PSA screening of informed patients until new American Urological Association clinical guidelines on PSA screening are issued and disseminated.
  • Supports a patient’s choice to have a PSA test. The decision should be made between a man and his personal physician based on his individual status with respect to age, symptoms, family history or concerns about prostate cancer.
  • Supports American Cancer Society communications calling for far better processes of informed patient decision-making both prior to, and after, PSA screening in healthy men.
  • Opposes the elimination of reimbursement for an informed patient requesting screening.
  • Strongly recommends intensified National Cancer Institute focus and research investment in better early detection tests of lethal prostate cancers. We also recommend new public-private research partnerships drawn from substantially increased and coordinated research investments from the American Cancer Society (ACS) and the American Urologic Association (AUA) partnering with the NCI and PCF.  Such public-private partnerships will accelerate the discovery, testing, and validation in U.S. men of new biotechnologies for lethal cancer detection that are superior to PSA screening.
  • Calls for greater patient participation in clinical studies evaluating new genomics-based prostate cancer detection tests.
  • Calls for greater eligible patient participation in and physician referral of patients to ongoing new clinical trials evaluating Proactive Surveillance (watchful waiting).

Additional Observations

The USPSTF has heightened awareness with new data of the issue of severe complications and patient suffering from the overdiagnosis and overtreatment of indolent prostate cancers. In addition to the emotional and physical suffering experienced by men and their families, a recent cost-effectiveness analysis of PSA screening estimated that the cost of diagnosis and treatment is over $5,227,306 per patient to prevent one U.S. prostate cancer death.

The USPSTF’s position provides a teachable and actionable moment for the medical community to improve targeting of PSA screening in patients, reduce over-testing and improve processes of patient education on the risks of overtreatment from PSA screening.

In the abstract, “task force” recommendations can create patient confusion and may result in unquantifiable numbers of men who will get a delayed diagnosis of a lethal and curable cancer. However, it should be noted that the recommendation clearly states, “… while the USPSTF discourages the use of screening tests for which the benefits do not outweigh the harms in the target population, it recognizes the common use of PSA screening in practice today and understands that some men will continue to request and some physicians will continue to offer screening. An individual man may choose to be screened because he places a higher value on the possibility of benefit, however small, than the known harms that accompany screening and treatment of screen-detected cancer, particularly the harms of over diagnosis and overtreatment. This decision should be an informed decision, preferably made in consultation with a regular care provider. No man should be screened without his understanding and consent; community-based and employer-based screening that does not allow an informed choice should be discontinued.”

PCF is encouraged that the AUA has convened a panel of medical experts who work routinely with prostate cancer patients, to improve guidelines for more targeted use of the PSA test as a screening tool.

Moving Past the PSA Debate

The PSA test still has a role to play in early detection and treatment for millions of men. It should be noted that in the pre-PSA era, approximately 80% of patients who were diagnosed with prostate cancer, were already in advanced stages of the disease with metastatic cancer. Today, the number of patients who are diagnosed with metastatic disease at time of initial diagnosis is around 20%. In the past 15 years, the death rate has been reduced from 42,000 annually to 33,000.

The PSA debate can become moot with intensive and accelerated research that delivers a better test. For more than a decade, PCF has been supporting research to find new and better molecular biomarkers for prostate cancer. At PCF’s 2011 Scientific Retreat, data on 17 new biotechnologies that complement or have the potential to replace PSA screening was presented. Many of these biotechnologies have the potential to discern between indolent and lethal prostate cancers. Essential will be patient participation in clinical trials to evaluate these new tests. New data on urine and blood tests using genetic biomarkers also offer the promise of eliminating a large number of unneeded biopsies and subsequent unnecessary treatment.

Given the enormity of the problem of overdiagnosis and overtreatment, PCF is also supporting a $5 million research project, the National Proactive Surveillance Network, to determine which patients can be maintained on proactive surveillance and which patients need to be recommended for surgery or radiation. Additional clinical trials of proactive surveillance are urgently needed to develop guidelines for men whose cancer in not life-threatening.

About the Prostate Cancer Foundation

The Prostate Cancer Foundation (PCF) is the world’s leading philanthropic funder of pca research. Founded in 1993, PCF has raised $475 million and provided funding to more than 1,500 researchers at nearly 200 institutions in 12 countries. PCF advocates for greater awareness of the need for prostate cancer research and greater patient participation in research. More information about PCF can be found at pcf.org.

5 Responses

  1. Wow! By a million miles, PCF has registered the sanest reaction to the USPSTF recommendations that I’ve seen to date.

  2. Men will die needlessly if they follow the advice of the USPSTF not to test at all for prostate cancer. If you wait for physical symptoms to develop, the cancer is already at an advanced stage and might even have metastasized already. It has been acknowledged that in the PSA testing era, prostate cancer is increasingly being found at the earlier, more treatable stages. Abandoning the test will be a step backwards.

    All we ever hear about is vaguely “the issue of severe complications and patient suffering from the over-diagnosis and over-treatment of indolent prostate cancers.” There is no such thing as over-diagnosis. Either you have the disease in some form or you don’t. The biopsy indicates the aggressiveness of the prostate cancer by the Gleason score. If an indolent cancer gets treated anyway, that’s not the fault of the test. You don’t throw away a good tool because someone didn’t use it correctly.

    My aggressive (Gleason 9) prostate cancer was only detected by a suspicious PSA test. An ultrasound gave further reasons to be suspicious, by way of a shadow in the gland image, and the biopsy then confirmed it. This was over 7 years ago. I was treated with IMRT radiation and hormonal therapy and as of a few weeks ago, there is still no sign of recurrence. I am only alive today enjoying my extended family because of the PSA test.

    Manny R.

  3. Dear Manny:

    Once again … Thge USPSTF is not recommending that we shouldn’t test for prostate cacncer at all. The USPSTF is recommending that healthy, symptomless men should only be tested for prostate cacner with a PSA test after being clearly informed of the risks and the benefits of such testing, which most certainly include risk for over-treatment and risk for excessive biopsies.

  4. I worked in STD prevention (in DHHS) for many years and discovered that, where public health is concerned, a relatively simple message was needed. If men believe that condoms may contain holes (as some groups wanted to label this product), they will tend to use this as an excuse to do what they want — avoid condom usage.

    I actually had a co-worker with stratospheric PSA levels who intentionally avoided biopsies because he was afraid of spreading the disease. He also avoided all treatment because … he hated all treatment. Finally, faced with the indisputable evidence of bony metastasis, he did take a palliative treatment of samariam — but of course the relief was temporary.

    How is warning men about the dangers of follow-up so different from forced warnings to women about abortions? The intent is to discourage the patient from this course of action.

    From my background, I really don’t think the government should be in the “discouragement” business — especially when there is a significant conflict of interest — the desire to keep health care expeditures down — that may affect these policy decisions.

    The Skeptic

  5. COST ESTIMATE PER DEATH AVOIDED PROFOUNDLY FAULTY

    I caught this article in a late review of accomplishments in 2011 (for which, congratulations!).

    I too am glad to see most of the statements in the PCF position. However, if we resist being swept up in this fine rebuttal to the USPSTF, we can see one glaring exception, the statement: “… a recent cost-effectiveness analysis of PSA screening estimated that the cost of diagnosis and treatment is over $5,227,306 per patient to prevent one U.S. prostate cancer death.” We need to take sharp exception to that statement because the cost analysis is based on a foundation of sand on a beach! None of the screening studies, especially PLCO and ERSPC, have accumulated patient follow-up since diagnosis anywhere near the point that the benefits of screening might begin to become apparent. Therefore, it should be clear that it is impossible to confidently estimate the number of deaths prevented. Hence, it is impossible to associate a cost figure with deaths prevented. I am convinced that the deaths avoided figure will rise substantially as the studies reach the 20-year point. (PLCO is now at about 15, with 13 reported.) That should sharply reduce the cost-per-patient for death avoided.

    This is based on the firmly established figures for survival of low- and intermediate-risk prostate cancer patients in the US of virtually 100% at 10 years from diagnosis, and about 95% survival of even high-risk patients at that point. I would like to add that the PLCO trial with its 13-year follow-up for over 50% of patients has bolstered these figures, but it must be true that PLCO had few if any patients with survival since diagnosis at that point. As the editorial in the New England Journal of Medicine put it about the original PLCO report in 2009, the findings may have been premature: i.e., “… Both decisions to publish now can be criticized as premature.” No kidding!

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