PSA testing: It's not your choice, it's the patient’s

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Dr. RosevearI’ve been a urologist long enough that a few things have started to bother me. One of them is the way primary care doctors are using the PSA test. I realize that for most urologists reading this blog, I will be preaching to the choir, but my hope is that primary care providers will take a few minutes to consider my message as well.

I have been practicing now for about 18 months, and I recently diagnosed my sixth patient under 70 with metastatic prostate cancer. Two of them are in their fifties. This is not a patient population that I encountered in residency and given their diagnosis and prognosis, it is a group I keep a close eye on.

All six were some version of the same story, including a multi-year history of slowly worsening lower urinary tract symptoms that have been refractory to a variety of oral medicines. Eventually, the symptoms became unbearable and they were sent to me for further treatment. None had had either a rectal exam or a PSA in years. All had been told that rectal exams and PSA were useless, and most could even describe the U.S. Preventive Services Task Force (USPSTF) recommendations on PSA screening. Not surprisingly, all were initially surprised that prostate cancer was even on my differential and all were shocked with the final diagnosis. One of them is actively seeking legal advice.

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This raised two critical points in my mind: first, the difference between screening someone for prostate cancer with PSA and diagnosing someone with prostate cancer; and second, the proper use of PSA as a screening tool.

Regarding the first point, I believe that once the USPSTF gave PSA screening a “D” grade, primary care providers simply stopped using it. (I could find no paper or evidence to support this belief, though in conversation with numerous primary care providers, I think this is true.) That is a mistake. Men with risk factors for prostate cancer who are exhibiting potential signs of the disease should have their PSAs checked not to “screen” them but rather to “diagnosis” them. I am unsure medicolegally how you can justify not checking a PSA in a man with a family history of prostate cancer and worsening obstructive voiding symptoms despite oral anti-BPH treatment.

Next: PSA as a screening tool

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Second, let’s look at PSA as a screening tool. Before anyone sends me links to the USPSTF website, which very nicely summarizes the risks associated with treatment of prostate cancer, let me just say I get it. I understand that the treatments that we have for prostate cancer carry potential significant complications. But so does metastatic prostate cancer. With that in mind, I sat down and read the entire USPSTF recommendation on PSA screening (not just the summary highlighted with a red “D”), as well as the American Cancer Society’s recommendation on PSA screening, the AUA guideline on the early detection of prostate cancer, the National Comprehensive Cancer Network’s Guideline on early prostate cancer detection, and the most current results of the European Randomized Study of Screening for Prostate Cancer. While there was a great deal of conflict among all these recommendations, one concept could be found in all of them: the concept of allowing the patient to make an informed decision.

Here is the American Cancer Society’s verbiage (my emphasis): “The American Cancer Society (ACS) recommends that men have a chance to make an informed decision with their health care provider about whether to be screened for prostate cancer. The decision should be made after getting information about the uncertainties, risks, and potential benefits of prostate cancer screening.”

Here is the line from the USPSTF (again, my emphasis): “The decision to initiate or continue PSA screening should reflect an explicit understanding of the possible benefits and harms and respect patients' preferences. Physicians should not offer or order PSA screening unless they are prepared to engage in shared decision making that enables an informed choice by patients. Similarly, patients requesting PSA screening should be provided with the opportunity to make informed choices to be screened that reflect their values about specific benefits and harms.”

These statements made me think about how I counsel patients on the risks and benefits of PSA screening. I quickly realized that it takes me, a (hopefully) soon-to-be board-certified urologist who tends to speak too quickly, about 15 minutes to have this conversation with a patient. Just think about what you have to cover:

how the PSA test works

its problems with false positive and false negatives

what comes next if it is elevated

the data on whether treating screen-detected prostate cancer save lives

how prostate cancer is treated

the complications of treating prostate cancer

the risks of not being screened, ie, the limited options we have for curative treatment of locally advanced or metastatic disease.

Therein lies the problem. Most primary care doctors I know give their patients between 8 and 10 minutes per visit and hence do not have the time to sit down and discuss this topic in detail. I get that too. Primary care doctors see more patients per day than I do and tend not to have the luxury of time that I do. Hence, here is my plea. If you as a primary care doctor do not think that you have the time or ability to walk a patient through the share decision-making process, then send the patient to me and I will.

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I will have the conversation because I believe that prostate cancer is a real disease and one that kills. I also believe that we are in the midst of a great government-led medical experiment involving prostate cancer. This is the first time to my knowledge that institutions are actively telling the public to stop using a test that has been credited with causing a huge stage migration. The wiser (ie, older) urologists among us will remember when the vast majority of prostate cancer presented either locally advanced or metastatic, whereas for urologists in my generation, those cancers are (were?) the exception.

There is a great graph from the SEER website that shows the incidence of prostate cancer from 1975 to 2011. It shows a spike in incidence in the early 1990s that is attributed to the widespread implementation of PSA. When that curve is drawn again 10 years from now, what is it going to look like? Are we going to see the reverse? A huge decline in the incidence followed by a rise again as all of those patients who could have been detected earlier now present with later stage disease? What are we going to call that? A stage remigration? A stage emigration?

Next: "The use of PSA is not straightforward"

The use of PSA is not straightforward. It’s not simple or easy. But the last time I checked, we physicians went to school for a long time so that we could explain complicated problems to our patients. While the days of the widespread, indiscriminate use of PSA are gone, we should not allow the pendulum to swing so far in the opposite direction that either patients with potential symptoms of prostate cancer have delays in their diagnosis or that patients aren’t given the opportunity to have their early-stage disease diagnosed when curative options still exist.

As for me, I intend to be screened. For me, the risks of incontinence and impotence matter less than the risk of early death from prostate cancer. But that is a decision I made regarding my health-a decision that some patients today are being denied.

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