of Routine PSA Screening
By Tanner Miest, MD, PhD
Over the past decade, conflicting guideline recommendations have led to a decrease in the routine use of prostate-specific antigen (PSA) blood tests for prostate cancer screening.
Unfortunately, newly published data from a large cohort study suggests that this decline has been associated with a corresponding increase in metastatic prostate cancer rates. These data highlight the important role PSA screening plays in early detection and support its appropriate use by all physicians in the primary care setting.
The report, published in the Oct. 24 online edition of JAMA Oncology, followed approximately five million men ages 40 and older between 2005 and 2019, seen at 128 Veterans Health Administration (VA) facilities nationwide.
Annual PSA screening rates decreased from 47.2 percent in 2005 to 37 percent in 2019. Metastatic prostate cancer incidence, meanwhile, increased from 5.2 cases per 100,000 men to 7.9 cases per 100,000 men. Additionally, VA facilities with higher screening rates were associated with lower rates of metastatic prostate cancer in the next five years.
This represents the strongest evidence published to date on the beneficial impact of routine PSA screening. The National Comprehensive Cancer Network now recommends annual PSA screening for all men 45 to 75, with testing beginning at age 40 for higher-risk patients.
Localized prostate cancer is often curable with surgery or radiation; in some cases, treatment can be deferred as patients undergo active surveillance.
However, once prostate cancer has metastasized, it is treatable but no longer curable. It frequently requires lifelong treatment – including androgen deprivation therapy and, in some cases, chemotherapy – that can negatively impact health and quality of life.
Androgen deprivation therapy involves medications that eliminate testosterone, starving prostate cancer of its primary growth signal. However, most patients experience side effects, including fatigue, decreased energy, loss of muscle mass, sexual dysfunction, declining bone and heart health, and mood disorders. Cancer also often becomes resistant to treatment.
Despite the known benefits of early detection, recommendations for routine PSA screening have been mixed. Notably, the 2012 guidelines from the U.S. Preventive Services Task Force (USPSTF) stated the risks of false positives, prostate biopsy complications and over-diagnosis of low-risk cancer outweighed the potential benefits.
The USPSTF based its recommendations on two large clinical trials evaluating PSA screening, one in Europe and the other in the United States. While the European Randomized Study of Screening for Prostate Cancer found a mortality benefit of more than 20 percent for men receiving routine PSA testing, the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial from the National Cancer Institute found no evidence of mortality benefit for routine versus opportunistic PSA screening.
However, it’s important to highlight that the PLCO study had a flawed design that led to a substantial number of men in the control group receiving PSA testing as part of their usual medical care.
Therefore, and in agreement with the recent study from JAMA Oncology, urologists strongly agree that appropriately-used PSA screening increases early detection of prostate cancer and decreases the risk of incurable metastatic disease.
Moving forward, it should be the goal of all physicians to use this tool as often and as effectively as possible to benefit our patients.
Dr. Miest is a fellowship-trained subspecialist in Urologic Oncology, based at Urology of Virginia’s office in Virginia Beach. urologyofva.net