Reaching the end of PSA screening

In the summer of 2007, then-U.S. Preventive Services Task Force member Russ Harris, MD, MPH approached me about taking on what he suggested would be a fairly quick and straightfoward project: summarizing the small amount of medical literature on the benefits and harms of the prostate-specific antigen (PSA) test that is commonly used to screen asymptomatic men for prostate cancer.

Little did I know that this research and its implications would dominate the next five years of my career. There would be some good moments (my published systematic review of the topic was honored as AHRQ’s Article of the Year award in 2009) as well as many bad ones (encapsulated in this series of posts that recount the reasons for my subsequent resignation from the Agency in 2010). This year, the USPSTF finally confirmed what had become clear to me and many other scholars of PSA screening: the test’s harms outweigh its benefits for the vast majority of men, and therefore it should not be recommended.

Although the Medicare program and private insurance plans continue to pay for the PSA test, there is reason to hope that the new recommendation will eventually change medical practice. Despite the backlash that greeted the USPSTF’s 2009 recommendation for individualized decision-making regarding mammography for women in their 40s, recent national data has demonstrated a 6 percent decline in screening rates in this age group – modest but notable evidence that more women are making thoughtful screening decisions that reflect their personal values and preferences.

Based on the USPSTF’s assessment, I now tell older male patients that the harms of the PSA test’s downstream consequences are very likely to outweigh any potential health benefits. Some still request the test, but such requests are becoming less common.

During the past five years, I have given countless lectures and participated in many public debates about PSA screening. I recently agreed to address the subject once more in October at a panel discussion sponsored by the Department of Health Policy and Management of the Johns Hopkins University Bloomberg School of Public Health (where I am an adjunct instructor). And I have decided that for me, that event will be the end of the line for public speaking about PSA screening, at least until there is more evidence to discuss. It’s time for me to move on, personally and professionally. Nonetheless, I hope that others will take up the essential task of communicating the flaws of this test to physicians and the public, so that someday we may reach the end of the line on PSA screening itself.

Kenneth Lin is a family physician who blogs at Common Sense Family Doctor.

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  • Margalit Gur-Arie

    What does “personal values” mean in this context (mammography screening)?

  • Barbara Fong Gress

    Cancer is not a diagnosis that runs in my family. In 2010 my brother had a “routine PSA” at the age of 62. It came back only slightly elevated from the prior year. He elected to immediately have a prostate biopsy. YES, he was found to have prostate cancer and an aggressive type. He had a prostatectomy within one month of the biopsies, He was found to have one positive node. So much for your research. He is alive to day thanks to the “routine PSA”. Somehow you may not recommend the test but I am glad he irgnored your recommendation. Of note is he practices internal medicine.

  • John Wickenden

    Thanks for the anecdote Barbara.
    It’s somewhat angry tone reminds me very much of the email reply from a friend I sent the USPSTF recommendation. He was indignant just as you are, citing that his brother and gay partner had both been diagnosed and “saved” by early treatment. Do you really think the task force, a carefully chosen body, did not take simple factors into account.
    Take a look at this recent page cited below about the same subject, bottom of page.
    Full of excellent information from oncogists etc, Roy Poses last point is that only 8.4% of subjects died within 15 years. Given their probably highish mean age I wonder if 8.4% wouldn’t die anyway. It also suggests your anecdote, something the USPSTF would recognize for what it is, is inaccurate. It is unlikely it is “thanks to the routine PSA test that my brother is alive”.
    Having said that I’m happy for you he is :-)

    • ChuckPilcher

      What is the definition of “screening”? Is a PSA appropriate as part of an evaluation for BPH?

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