Healthy men should not get routine prostate cancer screenings, says updated advice from a US government panel that found the PSA blood tests do more harm than good.
Despite strenuous protests from urologists, the US Preventive Services Task Force is sticking by a contentious proposal it made last fall. A final guideline published says there's little if any evidence that PSA testing saves lives - while too many men suffer impotence, incontinence, heart attacks, occasionally even death from treatment of tiny tumours that never would have killed them.
The guideline is not a mandate. The task force stresses that men who want a PSA test still can get one, but only after the doctor explains the uncertainties. That is in part because the panel found PSA testing hasn't been studied adequately in black men and those with prostate cancer in the family, who are at highest risk of the disease.
The Obama administration said Monday that the government health care plan for the elderly will continue to pay for PSA screenings, a simple blood test. Other insurers tend to follow the government's lead.
Be afraid of cancer
"This is important information for the public and men to have, and they should talk with their doctors about the risks and benefits of prostate cancer screening and make the decision that's best for them," said Mark Weber, a spokesman for the Department of Health and Human Services.
The task force advice goes a step further than major health groups including the American Cancer Society, which has long urged that men decide the issue for themselves after being told of PSA's pros and cons. But it is not likely to end an annual ritual for many men 50 and older. After all, the same task force has long urged men over 75 to skip PSA screening, and research suggests almost half of them still get tested.
The controversy will end only with development of better tests - to finally tell which men's tumours really will threaten their lives, and who will die with prostate cancer rather than from it, said Dr Virginia Moyer of the Baylor College of Medicine, who heads the task force.
"We have been told for decades to be terrified of cancer and that the only hope is early detection and treatment," she said. The reality: "You don't need to detect all cancers."
PSA’s value underestimated
"We don't want this to be the answer," Moyer added. "We want to screen for the ones that are going to be aggressive, manage those early - and leave everyone else alone."
In an editorial published with the guideline in Annals of Internal Medicine, some urologists argue the panel underestimated PSA's value and overestimated its harms.
"What PSA screening offers the men is a substantial opportunity to avoid dying a particularly unpleasant death from prostate cancer," said editorial co-author Dr William Catalona of North-western University, who pioneered the testing.
He spoke from a meeting of the American Urological Association, where doctors debated the guideline's impact. The urology association advises that men be informed of the potential risks and benefits before screening.
Too much PSA signals cancer is brewing
But Dr Otis Brawley, the American Cancer Society's chief medical officer, welcomed the task force's recommendation. He hoped it would help deter mass screenings, where men are given free PSAs at shopping malls and sports arenas without being told of the controversy, screenings that Brawley calls big business when health centres profit from the follow-up care.
"The question is, are we actually curing anybody who needs to be cured right now?" Brawley asked.
Too much PSA, or prostate-specific antigen, in the blood only sometimes signals prostate cancer is brewing. It also can mean a benign enlarged prostate or an infection. Only a biopsy can tell. Most men will get prostate cancer if they live long enough. Some 240,000 US men a year are diagnosed with it, most with slow-growing tumours that carry a very low risk of morphing into the kind that can kill.
To evaluate whether routine screening saves lives, the task force analyzed previous research, focusing in particular on two huge studies in the US and Europe. The panel's conclusion:
-Without screening, about 5 in every 1,000 men die of prostate cancer over 10 years. The European study found PSA testing might prevent one of those deaths, while the US study found no difference.
Death risk the same in US and Europe
-Of every 1,000 men screened, two will have a heart attack or stroke from resulting cancer treatment, and 30 to 40 will experience treatment-caused impotence or incontinence.
-Of every 3,000 men screened, one will die from complications of surgery.
Both the US and European studies have flaws, and task force critics argue over which are most believable. And while US death rates from prostate cancer have dropped over 20 years, the cancer society's Brawley says the drop began before PSA testing became widespread. Moreover, the risk of death is the same in Europe and the US even though many more American men are screened, diagnosed and treated, he said.
Maximise benefits of screening
"We need to do a better job of using PSA wisely," said Dr Scott Eggener, a University of Chicago prostate cancer specialist who was disappointed the task force went so far. "Most people would agree that a well-informed, young, healthy patient should have the opportunity to talk about it with their physician."
But he is studying a way beyond the screen-or-not controversy: Having men with small, low-risk tumours postpone treatment in favour of "active surveillance," keeping close watch on their tumours and treating only if they grow. More than 100,000 men a year are candidates, concluded a recent meeting at the National Institutes of Health.
That approach could "maximise the benefits of screening," Eggener said.
(Lauran Neergaard, Sapa, May 2012)