To screen or not to screen for prostate cancer?

Abstract

Does earlier diagnosis lead to better clinical outcomes? Many physicians and patients will probably answer yes. Thus screening tests are commonly done with good intentions of enabling earlier intervention and management to reduce mortality and suffering. However, inappropriate screening can harm healthy people as a result of overdiagnosis, overtreatment, and negative psychological effects. Prostate-specific antigen (PSA)-based prostate cancer screening is a case in point.Prostate cancer often has an indolent natural history, and patients are more likely to die with than to die from the disease. There is reliable evidence that PSA testing results in considerable overdiagnosis and overtreatment of men with prostate cancer, while associated potential harms include pain, fever, bleeding, infection, and transient urinary difficulties resulting from prostate biopsy, as well as erectile dysfunction, urinary incontinence, and bowel dysfunction.On May 22, after reviewing the evidence on both benefits and harms of PSA testing, the US Preventive Services Task Force (USPSTF) concluded that the reduction in prostate cancer mortality after PSA testing was very small and that the benefits did not outweigh the harms. Their recommendations are against PSA-based screening for the general US population of men at any age. Not surprisingly, the USPSTF recommendations have ruffled the feathers of some physicians. The American Urological Association (AUA) was outraged and released a statement disputing the recommendations. Furthermore, a survey of 125 primary care physicians and nurse practitioners from Johns Hopkins Community Physicians found that fewer than 2% of participants planned to follow the recommendations and completely stop ordering routine PSA-based screening.Although substantial changes to clinical practice may be unlikely in the USA, the recommendations create an opportunity to raise public awareness about the PSA test. Men concerned about prostate cancer should be informed of benefits and harms of the PSA screening prior to the test, so they can be empowered to make better shared decisions about their care and treatment with their physicians. Does earlier diagnosis lead to better clinical outcomes? Many physicians and patients will probably answer yes. Thus screening tests are commonly done with good intentions of enabling earlier intervention and management to reduce mortality and suffering. However, inappropriate screening can harm healthy people as a result of overdiagnosis, overtreatment, and negative psychological effects. Prostate-specific antigen (PSA)-based prostate cancer screening is a case in point. Prostate cancer often has an indolent natural history, and patients are more likely to die with than to die from the disease. There is reliable evidence that PSA testing results in considerable overdiagnosis and overtreatment of men with prostate cancer, while associated potential harms include pain, fever, bleeding, infection, and transient urinary difficulties resulting from prostate biopsy, as well as erectile dysfunction, urinary incontinence, and bowel dysfunction. On May 22, after reviewing the evidence on both benefits and harms of PSA testing, the US Preventive Services Task Force (USPSTF) concluded that the reduction in prostate cancer mortality after PSA testing was very small and that the benefits did not outweigh the harms. Their recommendations are against PSA-based screening for the general US population of men at any age. Not surprisingly, the USPSTF recommendations have ruffled the feathers of some physicians. The American Urological Association (AUA) was outraged and released a statement disputing the recommendations. Furthermore, a survey of 125 primary care physicians and nurse practitioners from Johns Hopkins Community Physicians found that fewer than 2% of participants planned to follow the recommendations and completely stop ordering routine PSA-based screening. Although substantial changes to clinical practice may be unlikely in the USA, the recommendations create an opportunity to raise public awareness about the PSA test. Men concerned about prostate cancer should be informed of benefits and harms of the PSA screening prior to the test, so they can be empowered to make better shared decisions about their care and treatment with their physicians.