PSA testing of the right individuals (not mass screening) should be the goal

A new article by Roobol, Bagma, and Loeb in the most recent issue of the Canadian Medical Association Journal argues that the use of PSA testing for risk of prostate cancer should primarily be focused on relatively younger men and that it should be avoided in older men with relatively poor health and low life expectancy. Dr. Roobol was one of the key researchers in the European Randomized Screening Study for Prostate Cancer (ERSPC).

Unfortunately the full text of this article is not available online unless you are a subscriber to the journal (or you are willing to pay for a copy), but a summary is available on the MedPage Today web site.

The full article is an opinion piece and offers no new actual data. The primary message being delivered by Dr. Roobol and her colleagues is that we need to be a great deal more thoughtful about the appropriate use of PSA testing for risk of prostate cancer. It is not simply a “screen everyone or test no one” issue, and the media hype that is focused on that “all or nothing” approach is not exactly constructive. This is a position that The “New” Prostate Cancer InfoLink can fully endorse — although the Devil is, as usual, in the details.

Roobol et al. also seem to consider that the currently drafted “D” recommendation (that all PSA testing in otherwise healthy men is inappropriate) from the U.S. Preventive Services Task Force (USPSTF) is misguided because it utterly ignores the fact that significant numbers of men are at known, elevated levels of risk for prostate cancer, and that early identification of disease is not just about prostate cancer-specific mortality, it is also about the avoidance of metastatic disease in men at significant risk for this potential outcome (even if they do not actually die of their disease).

It appears to The “New” Prostate Cancer InfoLink that many experts on the diagnosis and management of prostate cancer now achieving a reasonable consensus on the appropriate use of PSA testing (even though a better test is still a key priority). The next key question is whether the USPSTF can be persuaded to clearly recognize that testing of individuals at elevated risk for prostate cancer is reasonable — even if mass, population-based screening isn’t.

So who, today, do we know is at elevated risk for prostate cancer. Well, the precise details are still debatable, but the appropriate groups certainly appear to include:

  • Men with a positive digital rectal examination (DRE)
  • Men of black African ethnic origin (specifically including African Americans and Afro-Caribbeans)
  • Men clearly exposed to certain types of pollutant (e.g., Agent Orange)
  • Men with an elevated baseline PSA taken prior to age 50
  • Men with a clear and evident family history of clinically significant prostate cancer.
    • This may not include all men who had a single grandfather, father, uncles, or brother diagnosed with and treated for low- or very low-risk prostate cancer in the past 20 years after the introduction of the PSA test.
    • It certainly does include anyone with a first- or second-degree relative who either died from or had metastatic prostate cancer or multiple family members with localized but intermediate- or high-risk disease

The fundamental position being taken by Roobol and her colleagues is that, while mass, population-based screening (e.g., testing of everyone at age 50 on an annual basis) can no longer be justified, there is still a clear role for appropriate testing of higher-risk individuals, based on the concept of “informed choice” and the use of well-validated risk calculation tools:

Overuse of screening for unhealthy men with a limited life expectancy should indeed be discouraged; however, the same does not hold true for young healthy men,

they write in their conclusion.

Rather than abandoning a … test that reduces death and suffering, efforts should be focused on selecting patients [who might benefit from PSA testing] more carefully.

2 Responses

  1. I’ve been saying this ever since someone introduced me to Yorkshire Pudding. I am that guy the USPSTF leaves out in their recommendation. As I have stated, if prostate cancer is that 20-year disease, then logic says screening the median aged 67-year-old man at Dx was not reasonable. But logic then also says it was appropriate for me to have been tested at age 44.

  2. Agreed … and if you had had a first PSA test at 40-45 years of age, in your case you would probably have been diagnosed then.

    Many others would have been told at that age that they had no apparent risk signal for prostate cancer and to come back in another 5 years; some others would have been told that they already had a PSA > 0.7 ng/ml and should therefore get regular tests every 1 or 2 years for a while to see if their PSA was rising.

    In my case, at age 64 this year, and with a PSA still under 1 ng/ml, I would have come the conclusion that the only real need for me to have further PSA tests would be if there was some form of symptomatic problem. (This is a conclusion that I have pretty much reached; it is my insurance company that keeps wanting me to have PSA tests.)

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