Kenneth Lin
First published 6/21/11 on Common Sense MD
In an editorial in this month’s issue of the Journal of Family Practice, Northeast Ohio Medical University dean and family physician Jeff Susman, MD joins the rising chorus of voices urging clinicians to stop offering the PSA test to screen for prostate cancer. Dr. Susman writes:
I am going to go out on a limb here and suggest that, until we have fundamentally changed strategies for targeted case finding or early intervention (think genomic and proteomic markers), it is time to stop this screening nonsense. The facts speak for themselves: A trial of 182,000 patients finds in a post hoc analysis of a very narrow population that death can be averted in one of 723 individuals who are screened. What about the complications associated with diagnosis, work-up, and treatment? It is time for urologists and primary care physicians to tell patients that PSA screening is unlikely to benefit them. Some of you will suggest that we counsel patients about PSA testing to facilitate informed decision-making. But do we advise patients to play the lottery or try futile therapies?
Notably, mortality results from one of the two “definitive” randomized studies of treatment versus watchful waiting for PSA-detected prostate cancer, the Prostate Cancer Intervention Versus Observation Trial (PIVOT), were presented in abstract format the annual meeting of the American Urological Association last month. In brief, PIVOT found no overall survival benefit in men who underwent surgery (radical prostatectomy) compared to men who did not. The only men whom the study suggested might benefit from surgery were those with a PSA of greater than 10 – in other words, those men who would be least likely to be identified via screening alone.
As we continue to wait for the long-delayed verdict of the U.S. Preventive Services Task Force on PSA screening, public opinion may finally be turning against the test, at least in older men with no realistic possibility of benefit. When primary care blogger Kevin Pho, MD recently proposed on the New York Times’s Room for Debate that Medicare stop paying for prostate screenings for men over 75, the majority of responses were favorable – a big difference from the way the USPSTF’s recommendation against screening in this age group was originally received back in 2008.
Thank you, Dr. Susman, for taking a public stand on PSA screening that is consistent with the scientific evidence and most likely to benefit patients. Hopefully, it will soon become obvious to all that discouraging the misuse of this test is not “going out on a limb,” but rather, should be the standard of care.
Kenny Lin is a family physician practicing in the DC area and writing at Common Sense Family Doc.
Care And Cost 
Just within the last week, weren’t we reading blog postings about how people often fail to think in statistical/analytical terms and often make decisions based on inaccurate perceptions? For many people, the fear of cancer trumps any rational approach to screening. Obviously, the PSA screening test has been over-sold by the health care profession, but there is a tremendous patient (and patient’s spouse/partner) push to screen. And we can’t forget about liability issues. Failure to diagnose is an ominous prospect for most physicians. If I don’t screen my patients for prostate cancer, what is my liability? Even if I have an informed discussion with a patient, what will be the patient’s level of trust if he develops metastatic prostate cancer a few years down the road (see first sentence of paragraph)?
About 4-5 times a year, I uncover localized prostate cancer in men under 65 by DRE alone. These men have normal PSA’s. (I know there are some who advocate abandoning the DRE as well.) Many of these men come back to thank me for being so thorough and finding their cancer early. One recently gave me a hug; all the while I was wondering if I really had done him a favor. As a clinician, I feel confused by all of this.
I’m glad you’re not my doctor. I am 43 years old with no history of prostate cancer and no symptoms. A PSA test found my Gleason 7 prostate cancer, which without treatment would almost certainly have been fatal.
You’re welcome to make cost arguments against PSA testing. You can even make a case based on the dangers of complications for those 723 patients who were screened (although I would prefer we talk about procedures to reduce the dangers of complications). But “nonsense”?
You go ahead and argue that my life was saved by overscreeening, but it wasn’t “nonsense.” It was a wise, caring physician who saved my life by giving me the test. If I had been your patient, your calculated negligence would have killed me.