March 12, 2018
In recent days Ben Stiller made headlines for his courageous and honest account of his prostate cancer diagnosis. He speaks candidly about how fortunate he was to have a doctor that did a baseline PSA test, even though it is not recommended by the US Preventive Services Task Force (USPSTF) guidelines. A PSA test is a non-invasive, safe blood test that measures amount of prostate-specific antigen (PSA) in a man’s blood and when monitored over time can be an early indicator of prostate cancer.
Mr. Stiller’s story highlights an issue that for too long has been overlooked. Getting this life-saving test should not come down to which doctor you choose. It should be standard.
My own urologic training spanned the time before and after the introduction of PSA. I’ve seen first-hand, the tremendous effect this simple blood test has had on the early detection of prostate cancer.
PSA tests have only been widely used since 1987. Prior to that more than half of men newly diagnosed with prostate cancer had advanced or metastatic cancer. As a result, during my residency, the commonest treatment performed for them was surgical castration.
But by 1992, only five years after PSA become widely available, about 95% of newly diagnosed men had early stage disease that was potentially curable by surgery or radiation. By 2004, rates of metastatic prostate cancer plunged to less than half the rate seen in 1990.
With those types of incredible results it was a surprise to me – and to many in the medical community – that the USPSTF advised against routine PSA tests in 2012. The organization changed the guidelines because of evidence that PSA tests led to over diagnosis of nonlethal cancers and needless suffering from the side effects of therapy for non-harmful slow-growing tumors.
The recommendation against routine screening was well intentioned. However, one of the large randomized screening trials on which their decision was based, has recently been discredited due to a flaw in screening protocols. A concurrent trial in Europe, called ERSPC, now has 13 years of follow-up evidence and shows that early PSA screening reduces the risk of dying of prostate cancer by 21 percent and reduces the need for advanced treatment of metastatic disease by 35 percent in men aged 55 – 69.
Many in the urologic community, including me, believe that declining use of PSA screening has already or soon will result in an increased incidence of advanced disease, which gives me a sickening “Back to the Future” feeling.
Whereas no physician wants to inflict needless suffering on patients detected with early stage, slow-growing prostate cancer, neither do we want to return to the bygone, pre-PSA days when prostate cancer was mostly incurable.
The question is this: Can we find a happy medium, whereby lives are saved but needless suffering avoided?
The USPSTF has said it is open to reviewing new data and will issue updated recommendations in 2017. I urge them to do so – as advancements in technology and more mature research study results have opened the door for a more rational approach to screening.
PSA remains a highly-effective means of detecting prostate cancer. But today – just four years after the Task Force’s declaration — we have a much more robust arsenal of tools and best practices that have been developed, implemented and verified. They have vastly improved the detection and treatment of prostate cancer, and – if followed – can eliminate the troublesome, time-consuming and costly effects of overtreatment. They include:
Establish a baseline. A baseline PSA test between the ages of 45 – 50 is highly-effective in predicting the lifetime likelihood of developing prostate cancer. Importantly, it identifies the subset of men at highest risk and who should be screened regularly while determining those at lower risk who can be screened at longer intervals.
Better tests. Blood- and urine-based tests — some in use now, and others in development — are now substantially more accurate than PSA. Many are calibrated to better detect only higher grade cancers that need aggressive treatment.
Smarter screening. If, at age 60, a man’s PSA level is below 2, he is at a very low risk of developing incurable prostate cancer during his remaining lifetime. Thus, we can stop or vastly decrease the frequency of screening.
More MRI. Magnetic resonance imaging (MRI) technology is now sufficiently refined to not only target suspicious lesions for biopsy, but to reduce the likelihood of finding a low grade cancer that need not be diagnosed or treated.
Embrace “active surveillance.” Men initially diagnosed with low-grade cancer (confirmed by a biopsy, MRI and/or genomic tests) may avoid or delay treatment unless there are signs the cancer is advancing. Three studies have demonstrated the safety of this approach.
Adopting these suggestions will substantially reduce the harm associated with screening, while maintaining its positive benefits – that is, identifying the men with aggressive prostate cancer who are potentially going to die if not treated.
The time has come to reopen the dialogue about prostate screening. Doing so will lessen the likelihood of making an ill-informed choice with regard to testing in the future.
Eric A. Klein, MD, is the Chairman of the Glickman Urological & Kidney Institute and a staff member in the Taussig Cancer Institute at Cleveland Clinic. His clinical interests are cancers of the prostate, testis and kidney.