Appropriate use of the PSA test for assessing risk of prostate cancer

The following quotation is from the abstract of a recent review of the appropriate use of the PSA test in the assessment of risk for prostate cancer:

After the publication of two randomized trials on [prostate cancer] screening using the PSA test, it is generally accepted that systematic PSA-based screening, as compared to a clinical situation with virtually no screening, can reduce suffering from metastatic disease and [prostate cancer] mortality. However, what is also shown is that PSA-based screening coincides with a considerable amount of unnecessary testing and overdiagnosis. Should we abandon the use of the PSA test for the diagnosis of [prostate cancer], or should we encourage PSA testing and make it freely available for all men at any time? Both the answers should be “No.” What we must do is use the test as wisely as is currently possible and inform men who want to be tested, in a balanced way, about harms and potential benefits.

The statement appears in an article in Expert Opinion in Medical Diagnostics by Dr. Monique J. Roobol, one of the principal investigators of the European Randomized Study of Screening for Cancer of the Prostate [ERSCP].

It is a statement with which the “New” Prostate Cancer InfoLink is in complete agreement.

5 Responses

  1. I like her conclusions, but I’m curious whether she acknowledges the serious flaws in the ERSPC (and the PLCO trial). So many researchers and doctors seem to feel that randomization itself guarantees a sound trial, which is of course far from true, and definitely not true for the ERSPC and PLCO trials.

    I’m also curious whether she addresses the trend in ERSPC overall and sub-cohort results that are ever more favorable toward screening as the length of follow-up increases, especially as that follow-up time begins to enter what is arguably the zone of clinically meaningful results, given the long survival after diagnosis that is typical of prostate cancer.

    I see she is from the same institution as Dr. Fritz Schröder, who was the leader of the ERSPC, and a quick PubMed check showed they have been co-authors of 120 papers. It would really be really interesting to know what is in the rest of that paper available by subscription.

  2. Jim:

    Her e-mail address is avaialble on line … Write and ask her for a copy of the paper. She’s a very pleasant lady.

  3. Thanks. I’ve just done that.


    Thank you Sitemaster for recommending I contact Dr. Roobol. She responded quickly, and I’m very glad I’ve been able to read her full editorial.

    The editorial reflects a keen awareness of the deadliness of prostate cancer in the era before the PSA test, with one out of every two or three patients, diagnosed with the disease with the tools then available, primarily the DRE, dying from the disease. She also cites Dr. Catalona’s 1994 research showing tremendous improvement, due to the PSA test, in diagnosing disease when it was organ confined, and she notes the reduction in the burden of and suffering from metastatic disease. (I wish the US Preventive Services Task Force would take these points to heart.)

    Addressing the usefulness of the PSA test, she points to its use in risk stratification for men with a test in their 40s (study involved ages 44-50); the early level helped predict risk of advanced disease within 15 years. She notes that in a few men the disease can be lethal quickly, even at a young age. She points out that neither the DRE alone nor waiting for symptoms are good approaches, which is reassuring, as some in the policy community, such as the US Preventive Services Task Force, seem, in effect, to be advocating such an ostrich strategy.

    She displays a comparison of the AUA and the European guidelines for screening, with a link to an additional guideline, the guideline of the SIU, The International Society of Urology, to which she is one of two co-authors (along with Dr. Fritz. H. Schröder). Personally, I like the European guideline because it keys screening to what the patient knows: while opposing widespread screening campaigns, it affirms that “Rather, early detection (opportunistic screening) should be offered to the well-informed man.” I like that affirmation that screening “should be offered”. Also, I’m personally convinced that men need to understand the wisdom of the active surveillance approach for a diagnosis of low-risk prostate cancer, as well as understanding the other pros and cons, before being screened, before the emotion of an elevated risk can distort the information seeking and rational thought process of the patient and a mate. I also like the European recommendation of a baseline test at age 40 but with the interval for follow-up testing depending on the result. Finally, I like the European suggested screening cut-off only after age 75 for men with a PSA level of less than 3 ng/ml. I hope the AUA guideline will move in the direction of the European guideline.

    The SIU guideline for patients contains some key information on issues to be considered, but it does not mention active surveillance as a highly effective way to lower the risk of over-treatment, and it mentions side effects, particularly high levels of stress and anxiety, without noting that the side effects are infrequent, especially in an era of ever-growing knowledge and acceptance of active surveillance. However, the SIU parallel guideline for urologists addresses these issues much better. Among other points, that guideline for urologists highlights the dependence of announced benefit figures (numbers needing screening to save a life) on duration of median follow-up, and emphasizes that follow-up is both on the premature side (my word, but clearly implied) and increasingly favorable to screening as follow-up years increase (mentions ERSPC follow-up at medians of 9 and 11 years, and the Göteborg subset of ERSPC results at a median of 14 years). Moreover, the urologist version of the guideline emphasizes the role of active surveillance as an effective approach until a truly accurate marker is developed. At some point I hope the SIU will echo its emphasis on active surveillance that is in the guideline for urologists in its guideline for patients, pointing out that active surveillance is a way of sharply reducing the risks of over-treatment while preserving the benefits of needed treatment.

    Appropriately, Dr. Roobol’s conclusion emphasizes the importance of active surveillance, as well as minimizing over-treatment and striving for better biomarkers to replace PSA. I am quite reassured by the thoughts in this editorial. I am now at ease that the ERSPC leaders are well aware of issues that are key to me, particularly prematurity of follow-up data and the dependence of the survival benefit on follow-up, and that this awareness informs their recommendations to practicing doctors.

  5. “[I]nform men who want to be tested, in a balanced way, about harms and potential benefits.” Carries as much or more implication as the rest of the editorial.

    Practicing urologists and oncologists can not be realistically expected to both maintain their skill and experience, and additionally take the time necessary to inform and counsel so many men. Family medicine practitioners must keep up with far too many issues to be fully able to do the informing and counseling.

    This a a powerful argument for more nurses and social workers to specialize in urology and men’s health. Experienced laypeople must also play a much larger role helping men and partners. I hope that prostate treatment survivors might use the preventive care provisions of the Affordable Care Act to take these issues out of the hands of actuaries, and empower patient advocates.

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