BMJ clinical review discourages widespread prostate cancer screening

A clinical review in this week’s issue of the British Medical Journal (BMJ) states clearly that “Prostate cancer screening with the PSA blood test results in at most a small reduction in prostate cancer mortality and leads to considerable diagnostic and treatment related harms” and that “Physicians should recommend against PSA screening for prostate cancer.” This article by Wilt and Ahmed is a revised and updated version of a prior clinical review that also appeared in the BMJ.

American readers of this blog won’t be surprised by Dr. Wilt’s stance on this issue. Dr. Wilt was the lead investigator in the design and conduct of the PIVOT study that compared radical prostatectomy to expectant management in men with localized disease. He has also been a member of the of the U.S. Preventive Services Task Force. On the other hand, some readers may be surprised by Dr. Ahmed’s co-authorship of this paper since Dr. Ahmed is a urologist and a leading specialist in the treatment of prostate cancer in the UK. He has, for example, been heavily involved in the exploration of high-intensity focused ultrasound (HIFU) as a treatment for localized prostate cancer and the use of HIFU and other techniques in focal therapy.

As usual, The “New” Prostate Cancer InfoLink wishes to draw a very clear line in the sand to distinguish between “screening” (the mass, annual, population-based use of the PSA test) and “testing” of individuals based on actual risk (age, race, family history, and other factors) and possible, early, clinical indications of in individual patients (e.g., lower urinary tract symptoms or LUTS). We believe that the PSA test is a clinically useful test when used appropriately but that its current use is very definitely associated with (but not necessarily causative of) over-treatment — and arguably over-diagnosis — of clinically insignificant forms of prostate cancer.

4 Responses

  1. While I’m expecting to have to wait for a long, long time — since the vast majority of the US PCa clinical and advocacy community are so loathe to acknowledge, much less address, the harms of over-diagnosis and over-treatment (really, just treatment) — at some point the research and clinical community will have to address what it actually means to have a “family history” risk factor.

    Depending upon how one defines a “generation,” we now have an entire cohort of men subjected to the PSA screening era. Many, many of these men were over-diagnosed, over-treated, and permanently suffer the injuries of over-treatment. How in the world will we protect their sons and grandsons and nephews and brothers from being over-diagnosed and over-treated too? Who’s working on this problem?

  2. Tracy:

    At present I can only tell you what I think a wise advocate should mean by a “family history”.

    I believe that to be one of the following:

    — A single first-degree relative (father, brother) with metastatic prostate cancer (that may have led to his death)
    — At least two first-degree relatives diagnosed with localized prostate cancer
    — At least three first- or second-degree relatives (grandfather, father, uncle, brother) diagnosed with localized prostate cancer
    — A clear family history in which a diagnosis of prostate cancer has been commonplace across three or more generations

  3. Tracy asked, “Who’s working on this problem?”

    The doctors who are treating men with HIFU, all the men that I know personally — and I know quite a few at this time who have been treated with HIFU — have had no side effects, other than a bit of ED for a few months, as I experienced.

  4. Here I must disagree about the screening concept. If 10 men go to their doctor for a check up without any symptoms and no family history of cancer and the doctor does a PSA, they are being screened. It does not have to be done on large numbers of men at one location on one day. Testing asymptomatic people is screening and whether it is mass screening or individual screening, conclusions of Wilt and Ahmed apply.

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