Another eminent urologic oncologist on the USPSTF recommendation

The following editorial commentary related to the USPSTF recommendation was published on Friday, October 13, 2011 on the UroToday web site and is reproduced here with the permission of UroToday. The commentary was written by Alan Wein, MD, who is (among other things) Professor and Chief of the Division of Urology at the University of Pennsylvania School of Medicine, Chief of Urology at the Hospital of the University of Pennsylvania, and Director of the Residency Program in Urology at the University of Pennsylvania at the Hospital of the University of Pennsylvania.

Screening for prostate cancer with PSA testing: current status and future directions

The US Preventive Services Task Force’s recent announcement with respect to the evaluation of routine PSA screening was a very interesting one to me.

From the standpoint of physicians who actually take care of these patients, and recognizing that oncologists certainly share in the treatment of patients in the late stages of the disease, my own personal philosophy can be spelled out quite simply.

Certain facts are irrefutable:

  • The mortality from prostate cancer has decreased coincident with the use of PSA screening.
  • There has been a stage migration in diagnosis, meaning that it is much less common to see patients presenting with metastatic or even extensive local disease.
  • It is illogical to assume that late, advanced disease is as easily cured or successfully managed as early stage disease.
  • There is no question that there are some patients who are over-treated.
  • There is no question that some patients are not fully informed of the risks of various types of active management; further, some patients remain relatively uninformed regarding active surveillance.
  • PSA screening cannot distinguish high-risk or aggressive disease from low-risk or non-aggressive disease.

With these facts in mind, my personal philosophy is that in general, patients with a life expectancy of less than 8-10 years (and I do not cite a specific age because age is very often unrelated to life expectancy) do not benefit from screening for prostate cancer. Patients with a life expectancy of greater than 8-10 years need to be asked, “If you had prostate cancer would you want to know about it, and would you want to participate in decisions regarding the type of management?”

This assumes that the discussion would include the alterative[s] to active surveillance. If the answer to this question is “Yes,” then I think the patient deserves to be screened with PSA testing and digital rectal exam (DRE). If the answer is “No,” then I think, with proper documentation, one can omit PSA screening. I do, however, believe a DRE should still be carried out since it checks not only for prostate abnormalities but for abnormalities of the rectum as well.

One point that bears mentioning is that it is generally not the urologist who initiates PSA screening but rather the primary care provider — whether a family physician, internist, nurse practitioner, physician assistant, or medical subspecialist.

Finally, if a patient chooses not to be screened for prostate cancer, there needs to be a prohibition disallowing him from seeking legal sanctions under the accusation of “failure to diagnose” — and the extensive ramifications that always go along with this sort of lawsuit.

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6 Responses

  1. Very much agree.

    Please note the following:

    For Immediate Release

    Contact: Merel G. Nissenberg (619) 518-6465, (858) 459-0631 or Stan Rosenfeld (415) 459-4668, (415)290-6060

    October 16, 2011 La Jolla, California

    The National Alliance of State Prostate Cancer Coalitions and the California Prostate Cancer Coalition emphatically reject the proposed “D” Prostate Cancer Recommendation of the U.S. Preventive Services Task Force (USPSTF).

    The proposed Guideline of the U.S. Preventive Services Task Force would recommend the PSA blood test for prostate cancer only if the patient has prostate symptoms. However, by the time a patient has symptoms the disease is usually late-stage (advanced) and cannot be cured. The USPSTF’s proposed “D” recommendation AGAINST THE USE OF PSA “in healthy (asymptomatic) men” is a mis-interpretation of existing clinical trial data that would discourage men from asking for the PSA and excuse their physicians from failing to offer and discuss it with them. The National Alliance of State Prostate Cancer Coalitions (NASPCC) and the California Prostate Cancer Coalition (CPCC) heartily endorse the use of PSA for men beginning at age 40 (35 if high-risk). It’s the best test we currently have for prostate cancer and, in conjunction with a digital rectal examination, it should be offered until more sensitive/specific biomarkers are approved by the FDA. NASPCC and CPCC do not support unnecessary treatment; however, the USPSTF Recommendation would prevent men with potentially deadly disease from learning their true diagnosis in time for curative care and would condemn them to a miserable death.

    According to Merel Nissenberg, president of CPCC and NASPCC, “Knowledge is power. Testing for and diagnosing prostate cancer does not have to lead to over-treatment; men with clinically insignificant prostate cancer can select Active Surveillance, and those with aggressive cancer can be treated. When balancing the possible side effects of treatment against the saving of a life, most men would choose to live.”


    The California Prostate Cancer Coalition (CPCC) is a coalition of doctors, prostate cancer survivors (and families), nurses, support groups and others concerned about prostate cancer in California.

    The National Alliance of State Prostate Cancer Coalitions (NASPCC) is an umbrella organization meant to encompass participation by all states – through their state prostate cancer coalitions, state prostate cancer task forces or state prostate cancer foundations.

  2. Dear Stan:

    The recommendation issued by the USPSTF does not actually “recommend” the use of the PSA test at all. Indeed, the draft recommendation states very specifically that, “This recommendation applies to men in the U.S. population that do not have symptoms that are highly suspicious for prostate cancer, regardless of age, race, or family history. The Task Force did not evaluate the use of the PSA test as part of a diagnostic strategy in men with symptoms that are highly suspicious for prostate cancer.”

    I am sorry to have to say that the continuous mis-representation of the USPSTF’s actual draft recommendation by some members of the advocacy community is misleading and unhelpful to men at potential risk for clinically significant prostate cancer, not to mention the men who are at little to no risk of this condition at all. It also demonstrates a sad lack of appreciation of the absence of data from randomized clinical trials that can support mass, population-based screening for prostate cancer (as opposed to the selective use of the PSA test by informed men and their clinicians). The fact that men found to have low- and very low-risk prostate cancer after a biopsy can be managed by active surveillance does not mean that they will be. Indeed, there are extensive data demonstrating that such men are still the exception as opposed to the rule.

  3. Sitemaster:

    So how would YOU address/find men at potential risk for clinically significant prostate cancer?



  4. Dear Stan:

    I believe firmly that there is an onus upon the primary care community to do exactly as Dr. Wein suggests, which is to initiate a conversation with the patient. A simple method for doing this has been carefully laid out by Gaster et al. For those men who want to know more detail before deciding whether they want a PSA test or not, there are a variety of relatively neutral tools available.

    As I have noted many times before, 5 out of 6 men in America today (i.e., 83%) will never be diagnosed with prostate cancer. (That’s quite apart from the men who will be diagnosed with low- or very low-risk disease and who may never actually need treatment.) Those 5 out of 6 men need to understand that if they get a PSA test and have an elevated PSA level, they are highly likely to be advised they need a biopsy, which will immediately place them at significant risk for infections and other complications that were never, in fact, necessary.

    As Merel well knows, I also think that any man who wants to have a PSA test after such a discussion and decision should be entitled to get such a test, and have it paid for by Medicare, Medicaid, or his insurance compay as appropriate. That, to me, is the key issue here — coverage for those who still want to have a PSA test after such a discussion and decision. There is no consensus about the value of PSA testing of uninformed men, and there probably never will be because we all know that a much better test is what is needed. We can all agree that men who actually want a PSA test should have it covered.

  5. Merel and I believe that until a baseline is established and then before any possible biopsy that an informative discussion should ensue with the patient and physician, but until then warning the man of all the possible bad outcomes is conducive to giving the man an excuse to not know what is going on in his body.

    Thanks for listening,


  6. Stan:

    That’s a point of view … However, I happen to find it very paternalistic. Why do we need to start from the assumption that all men are fools?

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