June 2011 · Vol. 60, No. 06: 319
The perils of PSA screening
Jeff Susman, MD
This issue includes a Priority Update from the Research Literature (PURL) that evaluates the results of 2 studies concerning PSA screening.1,2 No sooner had this PURL been completed than The New England Journal of Medicine (NEJM) published the results of a randomized controlled trial of radical prostatectomy vs watchful waiting in early prostate cancer,3- accompanied by an editorial titled, “Effective treatment for early-stage prostate cancer—possible, necessary, or both?”4 Meanwhile, we await the results of 2 trials being touted as definitive: the Prostate cancer Intervention Versus Observation Trial (PIVOT)5 and the Prostate testing for cancer and Treatment (ProtecT) trial.6
Keeping up with this area of practice is beginning to feel like a full-time job.
But I am going to go out on a limb here and suggest that, until we have fundamentally changed strategies for targeted case finding or early intervention (think genomic and proteomic markers), it is time to stop this screening nonsense. The facts speak for themselves: A trial of 182,000 patients finds in a post hoc analysis of a very narrow population that death can be averted in one of 723 individuals who are screened.2 What about the complications associated with diagnosis, work-up, and treatment?
It is time for urologists and primary care physicians to tell patients that PSA screening is unlikely to benefit them.
Some of you will suggest that we counsel patients about PSA testing to facilitate informed decision-making. But do we advise patients to play the lottery or try futile therapies?
The only men who stand to get even a small benefit from PSA screening are those in excellent health, and it is pretty darn hard to improve on that. I urge all of us to stop offering routine PSA testing and, when asked, to advise against this risky intervention.
- Djulbegovic M,
Neuberger MM, et al. Screening for prostate cancer: systematic review and meta-analysis of randomised controlled trials. BMJ. 2010;341:c4543.
- Crawford ED,
Black A, et al. Comorbidity and mortality results from a randomized prostate cancer screening trial. J Clin Oncol. 2011;29:355–361.
- Bill-Axelson A,
Ruutu M, et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med. 2011;364:1708–1717.
- Smith MR.
Effective treatment for early-stage prostate cancer—possible, necessary, or both? N Engl J Med. 2011;364:1770–1772.
- Wilt TJ,
Barry MJ, et al. The Prostate cancer Intervention Versus Observation Trial: VA/NCI/AHRQ Co-operative Studies Program#407 (PIVOT): design and baseline results of a randomized controlled trial comparing radical prostatectomy to watchful waiting for men with clinically localized prostate cancer. Contemp Clin Trials. 2009; 30:81–87.
- Lane JA,
Martin RM, et al. Latest results from the UK trials evaluating prostate cancer screening and treatment: the CAP and ProtecT studies. Eur J Cancer. 2010;46:3095–3101.
The Journal of Family Practice ©2011 Quadrant HealthCom Inc.