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Prostate Cancer Screening in 2013: Reports of its Death Are Greatly Exaggerated. Norm D. Smith, M.D. Associate Professor Co-Director Urologic Oncology University of Chicago. United States Preventive Services Task Force (USPSTF). USPSTF Warns Against Blood Test For Prostate Cancer

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prostate cancer screening in 2013 reports of its death are greatly exaggerated

Prostate Cancer Screening in 2013: Reports of its Death Are Greatly Exaggerated

Norm D. Smith, M.D.

Associate Professor

Co-Director

Urologic Oncology

University of Chicago

united states preventive services task force uspstf
United States Preventive Services Task Force (USPSTF)

USPSTF Warns Against Blood Test For Prostate Cancer

ABC World News - “An earthquake today in the debate over men and prostate cancer”

New York Times "PSA does not save lives, but results in needless medical procedures that have left tens of thousands of men impotent, incontinent or both”

united states preventive services task force uspstf1
United States Preventive Services Task Force (USPSTF)

Los Angeles Times -16-member panel determined whether widespread PSA testing saves enough lives to justify the considerable medical fallout

HealthDay - the task force studied "five trials, the two largest done in Europe and in the United States... found no reduction in deaths due to prostate cancer among men of all ages in the study who underwent PSA testing”

united states preventive services task force uspstf2
United States Preventive Services Task Force (USPSTF)

New York Times - Aetna and Kaiser Permanente said it was unclear whether they would continue paying for the test… United Healthcare and WellPoint said they would continue coverage

GQ Medicare "is required under a 2008 law to cover the PSA test annually for beneficiaries 50 years old and older. Presumably it would take an act of Congress to undo that coverage requirement. Medicaid coverage of the PSA test is a state by state decision."

united states preventive services task force uspstf3
United States Preventive Services Task Force (USPSTF)

No Urologists

Grade D recommendation against PSA-based screening for prostate cancer

“moderate or high certainty that the service has no net benefit… harms outweigh the benefits”

Discourage PSA screening

prostate test found to save few lives new york times march 2009

Prostate Test Found to Save Few Lives(New York Times, March 2009)

Last week, two major studies from the United States and Europe found that P.S.A. testing — the annual blood test used to screen men for prostate cancer — saves few if any lives, while exposing patients to aggressive and unnecessary treatments that can leave them impotent and incontinent

slide8

Prostate-Specific AntigenBest Practice Statement:2009 Update(American Urological Association)http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/psa09.pdf

results age 60
Results Age < 60

1

 0.9

 0.9

 1.4

0.8

 2.6

 1.4

adjusted for bias

0.6

sensitivity

unadjusted

 4.1

0.4

 2.6

 4.1

0.2

 6.1

.69 .86

p = 0.0001

 6.1

0

0

0.2

0.4

0.6

0.8

1

1-specificity

results age 601
Results Age > 60

1

 1.1

 2.1

 1.1

0.8

 2.1

adjusted for bias

0.6

 4.1

sensitivity

unadjusted

 4.1

0.4

 6.1

 6.1

0.2

.62 .72

p = 0.008

 10.1

 10.1

0

0

0.2

0.4

0.6

0.8

1

1-specificity

t1c patients with rrp by psa at diagnosis psa follow up study
T1c Patients with RRP by PSA at Diagnosis ( PSA Follow-up Study)

1.0

2.6-4.0

4.1-6.0

6.1-9.9

> 10

.9

.8

.7

.6

Probability of No PSA Progression

.5

.4

PSA correlates with 10-year progression-free survival rates

.3

.2

.1

0.0

0

20

40

60

80

100

120

Number of Months

baltimore longitudinal study on aging
Baltimore Longitudinal Study on Aging
  • Median PSA level:
  • Age 40-49 = 0.6ng/ml
  • Age 50-59 = 0.7ng/ml
  • 3-fold higher risk of prostate cancer within 10-25 years if PSA > median for age group

Fang et al. Urology, 58: 411, 2001.

odds ratio of subsequent prostate cancer diagnosis
Odds Ratio of Subsequent Prostate Cancer Diagnosis

Loeb S, Roehl KA, Antenor JA, Catalona WJ, Suarez BK, Nadler RB. Baseline prostate-specific antigen compared with median prostate-specific antigen for age group as predictor of prostate cancer in men younger than 60 years old. Urology. 2006;67(2):316-20.

psa kinetic parameters
PSA Kinetic Parameters
  • PSA Velocity
    • absolute change in PSA per year
    • Independent of baseline PSA value
    • Better for diagnosis
  • PSA Doubling Time
    • Time it takes PSA value to double
    • A function of baseline PSA (the higher the baseline, the longer it takes to double)
    • Not as useful for diagnosis
psa velocity for detecting life threatening pca when still curable
PSA Velocity for Detecting Life-Threatening PCa when Still Curable
  • For men with a consistent PSAV of >0.35 ng/ml/year, there is more than a 5-fold increased risk of PCa death in next 2-3 decades
  • Recommended to begin PSA testing at age 40 to acquire reliable PSAV data

Carter HB et al JNCI 2006;98:1521-7

slide38

Example of WHO Global Mortality Rate Trends

“The trends in prostate cancer mortality rates in examined countries suggest that PSA screening may be effective in reducing mortality from prostate cancer.”

take home messages for psa screening
Take Home Messagesfor PSA Screening
  • Initial PSA screening at age 40
  • If PSA higher than median for age, annual screening at minimum (perhaps 6 months)
  • Annual PSA screening at 40 for African-Americans and men with family history
  • Biopsy threshold 2.5 in men < 60
  • Consider biopsy for PSA velocity > 0.35
  • PSA screening likely saves lives