PSA screening for prostate cancer debated in Congress

Originally posted in MedPage Today

by Emily P. Walker, MedPage Today Washington Correspondent

A day after the American Cancer Society (ACS) released updated prostate cancer screening guidelines, the group’s chief medical officer was before Congress urging the government to fund research into alternative screening methods for prostate cancer.

PSA screening for prostate cancer debated in CongressOtis Brawley, MD, an oncologist and chief medical officer for the ACS, told the House Oversight and Government Reform Committee that the country needs to move beyond PSA tests and discover new screening modalities that can better detect only cancers that will turn deadly.

“We need a better test than PSA,” said Brawley, who is a vocal critic of over-reliance on PSA screenings and overtreatment of prostate cancer. “PSA is a lousy test. It misses as many cancers as it finds.”

Meanwhile, patient advocates — including including Betty Gallo, the wife of Dean Gallo, a congressman who died of prostate cancer; and Louis Gossett, Jr., an actor with prostate cancer — urged the panel to widely promote screening, especially among African-American men, who are at a higher risk for prostate cancer.

The panel also heard testimony from James Mohler, MD, chairman of the Department of Urology at Roswell Park Cancer Institute, where the PSA test was developed. Mohler told the committee that prior to the development of PSA, only 4% of men diagnosed with prostate cancer could be cured, and now five-year survival is nearly 100%.

But, he noted, widespread screening has led to the detection of more cancers, and raised the age-adjusted incidence of prostate cancer by 30%, resulting in an overall 36% reduction in deaths from prostate cancer.

“If we could achieve a 36% reduction in mortality in any other solid cancer in America, there would be cause for jubilation,” he said.

The two contradictory messages — screening will save lives, and screening is not proven to save lives and may cause more harm than good — fit perfectly with the hearing’s purpose, as stated by committee chairman Edolphus Towns (D-N.Y.): to discuss the “controversy over whether men should be screened for prostate cancer.”

By the end of Thursday’s hearing, that controversy remained.

“The reason we have uncertainty is we have three studies that show it doesn’t do anything, and one that shows it saves lives,” said Brawley.

Of the four studies to which Brawley is referring, two found a higher mortality rate among men who were screened for prostate cancer; one — a large U.S. study — found no difference in mortality rates among those screened and those not screened; and the fourth, a large European study, found that men who were screened were more likely to survive than those who weren’t (P=0.04).

“One of the greatest problems is that we do not yet have a test that distinguishes the kind of disease that needs treatment from the kind of disease that never kills, but needs to be watched,” Brawley said.

Mohler agreed with Brawley on that point. He told the panel that PSAs can be elevated for many reasons, and warned that “indiscriminate use of PSAs and aggressive diagnosis and treatment of prostate cancer is unlikely to impact significantly the survival of American men and may adversely affect the quality of life of American men.”

He recommended development of a blood or urine test that could be combined with PSA to indicate which patients will need a prostate biopsy. He said he also would like to see a tissue biomarker developed to indicate life-threatening cancer.

The new guidelines that ACS released this week recommend that beginning at age 50, asymptomatic average-risk men with at least a 10-year life expectancy should receive information that allows them to make an informed decision, in collaboration with their healthcare providers, about prostate cancer screening.

The new guidelines didn’t change much from the group’s 2005 version; however, they place a greater emphasis on physicians addressing the uncertainty of the science of prostate cancer.

“Our new guideline is that men should have a conversation with their physician and that conversation should include the uncertainties, the known and proven risks of screening, the possible benefits, and then men should make a decision on whether they do or do not want to be screened,” Brawley said.

While the guidelines promote informed decision-making, Brawley said the data show that such conversations with patients are not taking place.

Many doctors aren’t well-versed in the scientific data, he said, and tend to overemphasize the benefits of treatment and downplay the risks. Also, screening wasn’t taught in medical schools fairly recently, Brawley said. “They don’t understand why screening can be harmful, for example.”

What’s more, such conversations are lengthy and doctors are not paid for having meaningful conversations with patients, he said.

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