US PSTF & PCa Screening Controversy

The US PSTF recommendations have incensed the PCa community as a whole, reinvigorating efforts to develop more advanced diagnostic techniques as a way of avoiding over-treatment. Below, you’ll find a commentary by Dr. Faina Shtern, President of the influential AdMeTech Foundation.

US Preventive Services Task Force Recommends (US PSTF) Against PSA Screening: Transforming Controversy into a National Movement to Advance Diagnostic Tools for Prostate Cancer?

by Faina Shtern, MD

Based on the analysis of the scientific literature, US PSTF concluded that the benefits of the current screening tools (eg, PSA) are outweighed by their harm caused by widespread unnecessary biopsies and treatment. US PSTF recommended against the use of PSA for men in the general U.S. population; this recommendation does not apply to African American men and other vulnerable populations such as men with family history of prostate cancer or clinical symptoms http://www.uspreventiveservicestaskforce.org/draftrec3.htm and http://www.uspreventiveservicestaskforce.org/uspstf12/prostate/prostateart.htm.) This recommendation created an outcry in the medical and advocacy communities. American Cancer Society issued similar guidelines in March 2010, which also generated a heated debate.

Indeed, PSA is the best chance a man has today for early detection of prostate cancer, which is critical for saving lives. Prior to PSA, over 90 percent of men presented with advanced prostate cancer. Today, over 90 percent of men are diagnosed with earlier disease and according to the NCI cancer facts (http://seer.cancer.gov/statfacts/html/prost.html), have 100% probability of 5 year survival.

Recommendations by US PSTF and ACS raise a critically important question: is PSA the real culprit causing over-diagnosis and over-treatment? The conclusion of the recent large-scale, long-term study of prostate cancer mortality in over 11,000 men after radical prostatectomy was rather different: The authors pointed out that current diagnostics including random and blind biopsies over- or under-grade prostate cancer in the majority of men, and the lack of confidence in grading and staging is the major reason for over-treatment (1,2). The lack of accurate imaging tools and related poor biopsy guidance and sampling has been highlighted as the central factor in under-grading of prostate cancer prior to treatment in as many as 46% of men compared to histologic assessment of post-prostatectomy specimens (3). These studies concluded that more advanced diagnostic tools, including more specific biomarkers and imaging technologies were needed to reduce unnecessary and procedures. While US PSTF and ACS recommendations appear to make PSA responsible for over-diagnosis and over-treatment (and the related complications), the lack of imaging tools which will improve not only biopsy guidance, but also eliminate unnecessary biopsies altogether, wasn’t addressed. Similarly, the role of poor sampling of biopsies in missed and under-estimating prostate cancer and the related treatment failures have not been addressed. While prostate cancer is curable when detected early, it remains the second leading cause of cancer mortality in men; an American man dies every 16 minutes.

The magnitude of the prostate cancer epidemic, which strikes as many as 1 in 6 men, exceeds that of even breast cancer (afflicting in 1 in 8 women). And yet, the US PSTF and ACS recommendations highlight a continuous controversy, uncertainty and intense division in the medical community regarding the value of PSA in screening. Thus we have a choice: Either to invalidate PSA, or to focus on the critical need to develop improved biomarkers and imaging tools so that men with abnormal PSA will have appropriate diagnostic evaluation of prostate cancer aggressiveness and stage.

The current PSA debacle has an uncanny resemblance to the intense debate of 20 years ago regarding film-based mammography. At that time, the mammography controversy was turned into an opportunity to support research and development of advanced breast cancer imaging tools which transformed patient care by improving screening, early detection, saving lives, creating minimally-invasive, precisely-targeted biopsy and treatment. Reliable assessment of risk on mammography has led to reduction of unnecessary biopsies.

Recommendations by US PSTF and ACS bring into a sharp focus the critical importance of recognizing prostate cancer as a public health priority similar to breast cancer and focusing national attention on investment in research to develop advanced diagnostic tools which will drastically reduce over-treatment, over-diagnosis and failed procedures. This will not only save lives but will also improve quality of life in millions of men and reduce billions of dollars in health care costs.

How do we accomplish this goal? We must follow the model of breast cancer advocacy and awareness. Only last month, key Massachusetts legislators had set up a historic precedent by recognizing prostate cancer as a public health priority, central issue in men’s health and major disparity area  – and issued a call to action to advance early detection and treatment (visit http://www.admetech.org for more information). National movement modeled after breast cancer will bring Massachusetts State House model to US Congress.

In short, our goal must be to create a national movement akin to breast cancer to assure men’s access to PSA today and increased investment in research to improve diagnostics tools within the next 5 years. We need a Manhattan project for the facilitated advancement of prostate diagnostic tools and their transfer from laboratories to patients.

Perhaps it is time for us to lead One Million Man Petition to US Congress.  Please let me know if you would like to join us.

Faina Shtern, MD

President, AdMeTech Foundation

About AdMeTech Foundation: Boston-based nonprofit 501(c)3 organization has been providing international leadership in the design and implementation of groundbreaking programs in research, education and public awareness to improve early detection and treatment of prostate cancer.  Dr. Shtern can be contacted by email faina.shtern@admetech.org or phone 6175233535.

References:

1. Eggener SE, Scardino PT, Walsh PC, et al. Predicting 15-year PC specific mortality after radical prostatectomy.  J Urol. United States: Inc. Published by Elsevier Inc, 2011; p. 869-75.

2. Stephenson AJ, Kattan MW, Eastham JA, et al. PC-Specific Mortality After Radical Prostatectomy for Patients Treated in the PSA Era. JCO 2009; 27: 4300-4305.

3. Stackhouse DA, Sun L, Schroeck FR, et al. Factors predicting prostatic biopsy Gleason sum under grading.  J Urol. United States2009; p. 118-22; discussion 23-4.


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