Research indicates that since the introduction of prostate-specific antigen (PSA) as a blood test in 1992, the number of men diagnosed with prostate cancer has increased dramatically. However, in May 2012, the US Preventive Services Task Force issued a grade D recommendation against PSA-based prostate cancer screening, arguing that the effects of treatment outweighed the benefit of screening.
“The unintended consequences of this policy were: 1) potentially more men dying of prostate cancer, 2) more men suffering from the consequences of non-curative intervention (secondary interventions like radiation, hormone therapy, or both), and 3) psychological complications of recurrent prostate cancer,” says Thomas Ahlering, MD.
To assess the effect of decreased PSA screening on the presentation of high-risk prostate cancer post-radical prostatectomy (RP), Dr. Ahlering, Linda Huynh, MSc, and colleagues analyzed data from high-volume referral centers throughout the US. The research team propensity matched for age and PSA at time of radical prostatectomy, assessing the absolute number of patients with high-risk disease characteristics (Gleason grade, lymph node metastases, seminal vesicle invasion, etc.). Compared with the 4-year average prior to the recommendation, there was a 22.6% reduction in surgical volume, an increase in median PSA (from 5.1 to 5.8 ng/ml), and an increase in mean age (from 60.8 to 62.0 years) after the recommendation. Huynh adds that, most worrisome was a near-doubling of high-grade Gleason score 9-10 cancers, a 3.5-fold increase in men with advanced seminal vesicle involvement, a tripling of lymph node metastases, and an increase in 1-year biochemical recurrence post-RP rate from 6.2% to 17.5%.
“The most deleterious outcome of reduced screening is the increased risk of increasingly more aggressive disease over time,” says Dr. Ahlering. “While changes in age and lowgrade disease are congruent with the Task Force recommendation, the presently noted increase in men with PSA greater than 10 ng/ml is potentially a harbinger of further increasing risk for these issues.”
Dr. Ahlering stresses that the discussion of PSA screening should assess better solutions to address the primary issue for the Task Force recommendation. If the major reason for the D recommendation was the “complications” of treatment, that should be the central focus of change, he adds.