PSA for prostate cancer screening is likely to continue

Originally published in MedPage Today

by Crystal Phend

The ASCO Genitourinary Cancers Symposium met recently, just after the American Cancer Society updated its prostate cancer screening guidelines to emphasize shared decision making and Congress heard testimony over use of prostate specific antigen (PSA) in prostate cancer screening.

Now urology is no stranger to debate. Controversy continues on overdiagnosis, overtreatment, and other issues raised by use of PSA for screening.

But the emotional, anecdote-driven can of worms opened up last fall when the U.S. Preventive Services Task Force recommended against mammography for women under 50 sparked some fear of a repeat.

The Cleveland Clinic’s Eric Klein, MD, reportedly declared it impossible to change the prostate cancer screening guidelines now.

However, Ralph W. deVere White, MBBCh, director of the University of California Davis Cancer Center and the Society of Urologic Oncology steering committee for the ASCO GU meeting, thought that the “fair bashing over mammography” might actually persuade Congress to not force the issue.

He objected to the way the cancer society framed the discussion around all the possible negatives.

“I think a lot of men are going to look at that and say, You’re out of your mind, why would I want one?” he said in an interview.

Regardless, of what Congress ultimately decides to do, men are unlikely to be as vocal about prostate cancer screening as women were about mammography, deVere White noted.

ACS chief medical officer Otis Brawley, MD, who before Congress criticized PSA as a “lousy test,” said the guideline update isn’t really much of a change, although a change might be deserved.

“Everybody is saying screening only ought to be done among well informed men and among men who understand that there are significant uncertainties, men who understand there are risks to this, and men who understand there are possible benefits and want to take the test because of those possible benefits,” Brawley said when pulled aside after his ASCO GU talk.

Marketing and promotion, though, may tell a different story, highlighting how screening “saves lives” without giving the proper balance, he said.

Some men have gone into screening only to find that their elevated PSA levels, while not requiring prostate cancer treatment, make them uninsurable, Brawley warned.

“I had one of those guys come up to me at the hearing,” Brawley said in an interview. “He can’t change jobs. He’s been offered a better job with an incredible pay raise but because he has a history of elevated PSAs he can’t get insurance if leaves his current job.”

If healthcare reform passes, this impasse over preexisting “conditions” might disappear, Brawley acknowledged.

Meanwhile, it’s one thing that makes the federal government an attractive employer.

“The only major employer whose insurances routinely excuse preexisting conditions is the federal government,” Brawley said. “I actually know people who have gone to work for the federal government because that’s the only way they could get insurance.”

Crystal Phend is a senior staff writer at MedPage Today and blogs at In Other Words, the MedPage Today staff blog.

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