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in mind, my personal philosophy is that in general, patients with a life expectancy of less than 8-10 years (and I do not cite a specific age because age is very often unrelated to life expectancy) do not benefit from screening for prostate cancer.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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