The May 2012 recommendation by the U.S. Preventive Services Task Force (USPSTF) to stop routine PSA screening has been widely criticized by the urologic community, and rightfully so.
There is no test currently available to replace PSA. While PSA is far from a perfect test, the USPTF has done the U.S. public a disservice by disparaging the only screening test that is available. The decision to perform or not to perform a PSA screen should be left to the patient and their personal physician or urologist. I routinely discuss the risks and benefits of PSA testing with individual patients. Indeed, that decision is one that is individual and unique to each patient. It is unacceptable for the USPTF force to advocate against all patients having a choice regarding PSA testing.
Many of the arguments against PSA screening by the USPTF have been known for years. The urology community is a decade ahead of the USPTF in addressing these criticisms. For example, we recognized years ago that not all cases of early prostate cancer require treatment. Patients are now offered a program of “active surveillance” when they appear to have early, non-aggressive disease. However, only patients with acceptable PSA and biopsy findings can be deemed good candidates for active surveillance. If the USPTF recommendations were followed, patients with early, aggressive disease would be denied access to potentially curative treatment when the treatment is most likely to succeed.
The USPTF has overstated the risks associated with prostate cancer diagnosis and treatment. Serious, life-threatening complications occur in less than 1 in 1000 prostate biopsies. Urinary incontinence occurs in less than 5-percent of cases when treatment is administered by experienced specialists. Erectile dysfunction following treatment for prostate cancer is serious, but not life-threatening. Additionally, erectile dysfunction can be treated in almost every case when it does occur.
The benefit of PSA screening is starkly illustrated by comparing the prostate cancer death rates between countries where PSA testing is and is not performed. Sweden, for example, does not perform PSA testing and has the third highest prostate cancer death rate in the world. The U.S. ranks forty-sixth in the world (and falling!), in large part due to our widespread practice of PSA screening. Incidentally, the U.S. ranks first in the world for prostate cancer survival.
The recommendation by the USPTF must be viewed in the appropriate context. The USPTF did not include a urologist. The chairman, in fact, is a pediatrician. More importantly, the government and the health insurance industry stand to benefit financially from the discontinuation of PSA testing. If PSA testing is no longer allowed, early diagnosis and treatment of prostate cancer will rarely be practiced, thus saving the government and insurance companies additional dollars. Patients and their families will pay the higher cost in pain, suffering and grief.
I believe we can expect additional recommendations by the USPTF in the future aimed at eliminating or rationing healthcare in an attempt to reduce healthcare costs.
Finally, despite the recommendation of the USPTF, I believe the standard of care will require PSA testing in the foreseeable future. I predict a rise in malpractice cases in the future against physicians who stop offering annual PSA screening to patients based on the recommendations of the USPTF.
Copyright (C) 2019 Steven A. Johnson, M.D., P.A.
Dr. Johnson Responds to U.S. Preventive Services Task Force’s
Recommendation to Stop PSA Testing