Prostate Cancer: To Screen or Not To Screen; USPTSF Position On Prostate Cancer Screening
Prostate cancer screening is still the most controversial subject in the world. This is because Governmental agencies are more and more discouraging physicians to screen for prostate cancer.
A recent 2018 study from the United Kingdom (the CAP study) recently published an article in JAMA showing no difference in overall mortality between the screening group and non-screened group for prostate cancer. While it is evident that men are overly tested and treated for prostate cancer, "throwing out the baby with the bathwater," as they say, would be a brutality.
Recently, Dr. Geo Espinoza; one of the world finest Naturopathic Urologist email me an important blog and wants to share with my readers on prostate cancer screening. So in this article explains the USPSTF position on this topic, published on May 08, 2018, so you can best partner with your physician on whether or not to screen for prostate cancer.
The United States Preventive Services Task Force (USPSTF) is a government supported panel composed of national medical experts in primary care and researchers (no urologist or oncologist on the panel) who collectively review the evidence for what screening tools and treatments are most useful for patients.
The USPSTF has a grading system ranging from grade A, where the task force recommends for a service (screening or treatment) to grade D where the recommendation is against a service, and everything else in between. (see below chart).
In 2012 the United States Preventive Services Task Force (USPSTF) issued a report opposing the use of PSA in screening for prostate cancer and gave a grade “D” recommendation, discouraging physicians to screen for prostate cancer and that there is more harm than good with the use of the PSA test.
Then two years later after further data review, the USPSTF graded PSA screening to a “C,” suggesting that the decision on whether or not to screen for prostate cancer with PSA test should be shared between the physician and patient and it should be used selectively in a case by case basis.
Today, published in the Journal of American Medical Association (JAMA), the USPSTF concludes that there is a small overall benefit with the use of PSA in screening for prostate cancer, but continues to note that damages may occur during this screening process.
There is still a major age-related problem in this current recommendation because studies have predominantly included patients aged 55-70 years. Thus, the new USPSTF will not recommend PSA for men over 70 years nor for those under 55 years, which seems inadequate, given that it does not take into account clinical characteristics nor individual volition.
This new screening grade is important because the task force has an influence on how clinicians practice on what health insurance companies pay for.
Three Studies Driving Prostate Cancer Screening Controversy
Primarily, the two main trials influencing the USPSTF’s grading on prostate cancer screening are The European Prostate Cancer Screening Trial (ERSPC) and The American Prostate Cancer Screening Trial (PLCO) study. Now there is a more recent study, the Cluster Randomized Trial of PSA Testing for Prostate Cancer (CAP) that reinforces the task force position on screening.
The Cluster Randomized Trial of PSA Testing for Prostate Cancer (CAP)
This recent British study led by Martin et al 2018 entitled Effect of a Low-Intensity PSA-Based Screening Intervention on Prostate Cancer Mortality: The CAP Randomized Clinical Trial. ,was conducted in the United Kingdom, where about five hundred primary care practices in the United Kingdom were offered to screen men aged 50 to 69 years an invitation to a single PSA test (271 practices) and a control group that did not offer PSA testing (302 practices).
In an average of ten years follow-up, there was no all-cause mortality difference between the screened and the non-screened group.
In other words, men who were screened for prostate cancer died from any cause, not just prostate cancer as much as men who were not screened at all. As one would expect, there was an increase in low-risk prostate cancer detection in the screening group in the CAP study.
The European Prostate Cancer Screening Trial (ERSPC)
The ERSPC randomized trial of about 160,000 men between 55 and 69 years for PSA screening or control without PSA where the PSA average to indicate a prostate biopsy is ≥ 3.0 ng/ml. The PSA test was taken, on average, only every four years. After monitoring for 11 years, screening reduced the risk of metastases by 41% and the chance of death from prostate cancer by 21%.
More recently, the European ERSPC study, now with almost 14 years of follow-up, confirmed that prostate cancer mortality in PSA screened patients decreased by 32% suggesting that as time goes on study subjects continued to be followed, there will be more benefit from PSA screening.
On the other hand, ERSPC trial continues to show a major problem with over diagnosing for prostate cancer screening with PSA of clinically insignificant tumors. In fact, in the ERSPC study, the finding of low-risk tumors (PSA less than10 ng/mL and Gleason score less than 6) was almost three times higher in the screened group than the control group.
The American Lung, Colorectal, and Ovarian Cancer Screening Trial Trial (PLCO) study
Lastly in the American Lung, Colorectal, and Ovarian Cancer Screening Trial Trial (PLCO) study randomized over 76,000 men aged 55 to 74 years for annual screening with PSA and rectal exam or control group with the “usual urological care,” that is, at the discretion of the urologist.
The PSA value used to indicate biopsy was ≥ 4.0 ng/mL. This study initially showed no mortality benefit for men who received PSA screening in comparison with those who did not.
The problem in the PLCO trial was the control group. Since “usual care” in the USA includes PSA, in this case almost 90% of the patients in the “usual care” group did the test compared to the randomized group. Therefore, it is no surprise that the rates of prostate cancer death were similar to the screening arm.
When researchers combined all the major prostate cancer screening studies, they did not find a significant decrease in prostate cancer-specific mortality except in the ERSPC which screening did indeed lower prostate cancer mortality. The research led by Ilic et al 2013, titled Screening for prostate cancer published in the Cochrane Database Syst Rev.
They concluded that “Harms associated with PSA-based screening and subsequent diagnostic evaluations are frequent, and moderate in severity. Overdiagnosis and overtreatment are common and are associated with treatment-related harms.”
The Takeaway from the USPSTF on Prostate Cancer Screening
The task force grade recommendation for prostate cancer screening stays at a “C” which mostly means that you, the patient, can dictate whether or not you want to be screened for prostate cancer. If you do not want a PSA test taken, then you can decline, and in theory, your physician should be fine with it. Essentially, there is no grand change in the USPSTF recommendation from 2014, other than they are doubling down on their “C” grade reinforced by the CAP study.
Dr. Geo’s Guide to Prostate Cancer Screening & Protection
I am all for patient empowerment and for men partnering with physicians to improve his health. Furthermore, many of my patients, naturally, since I am a holistic practitioner, want to avoid biopsies.
I don’t blame them. I don’t know anyone who gets excited about having their prostate poked 12+ times and had blood come out their urine and semen for up to two weeks.
The evidence is clear that most men with high PSA scores, who get biopsied, do not have prostate cancer (what we call a false positive). It is also obvious, based on volumes of research that there is overtreatment of prostate cancer, meaning, most men with prostate cancer will not die from it making prostate cancer treated with either surgery or radiation old-fashioned.
Why not screen for prostate cancer and not treat if the outcome is low-grade disease?
Because that diagnosis is intimidating to your brain. It’s the “cancer” word. In other words, the problem in many cases is the diagnosis itself – it provokes anxiety and unease – so rather than letting those feeling linger “taking it out” is what many men opt for.
The problem is not the PSA test. And ignorance is not bliss. Before the late 1980’s most men diagnosed with prostate cancer had advanced disease, and those numbers went down drastically after the commercial use of PSA test. The problem is how the PSA number is used (or abused). As the CAP study revealed, just one PSA number that is relatively high does not dictate you have prostate cancer or that a biopsy is needed.
When I partner with patients to determine if avoiding a prostate biopsy is the right for them, we look at:
Age of the patient
PSA relative to age
PSA free percentage
The blood test 4K score
The urine test Select MDx.
If most of the results from testing indicate suspicious prostate cells, then we look into getting a 3-Tesla MRI. Still, no biopsy needed up to this point.
If the MRI highly suggested suspicious cells, typically of Gleason 7 or higher, then I would recommend a biopsy, but not a random ultrasound guided one, a targeted MR fusion biopsy.
The bottom line is how a physician uses a PSA test matters most, as imperfect of a biomarker for prostate cancer screening as it is, it saves lives. At a minimum, an elevated PSA can tell you if something wrong in the prostate, even if it’s not cancer, maybe inflammation or other benign development.
The ultimate goal of prostate cancer screening is this:
• Find a cost-efficient method of locating tumors that have the most life-threatening potential.
• Leave tumors that are not deadly alone, or better yet, not find them in the first place.
• Have a treatment that can remove the possibly deadly cancer without sacrificing quality of life.
The methods of the screening I highlight above provide the best chance of accomplishing the ultimate goal for prostate cancer screening.
Also, prevention is the best medicine.
When I say prevention, I also mean prostate cancer recurrence prevention or, if it returns, preventing spreading of cancer.
Nutrition and Lifestyle is real medicine.
Eat protective foods. A plant-based, Mediterranean method of eating is protective, and it’s the cornerstone of healthy Prostate.
Exercise four hours a week with moderate intensity.
Consume selected, targeted supplements from companies that exceed governmental quality manufacturing practices.
Thank You.. If you are concerned call 0208679076
Dr. Raphael Nyarkotey Obu is a Research Professor of Prostate Cancer and Alternative Medicine –Da Vinci College of Holistic Medicine, Larnaca City, Cyprus. He is the President of Nyarkotey College of Holistic Medicine, Near Tema community, 7 post Office
Disclaimer: "The views/contents expressed in this article are the sole responsibility of Raphael Nyarkotey Obu and do not neccessarily reflect those of Modern Ghana.