PSA Screening for Prostate Cancer Can Do More Than
In 2012, the U.S. Preventive
Services Task Force concluded that prostate cancer screening provides “very small potential benefit and
significant potential harms” and issued guidelines recommending against it. A new study by experts at Fred
Hutchinson Cancer Research Center, published today in the journal Cancer, explores the impact that stopping
prostate-specific antigen (PSA) screening would have on American men.
The researchers used statistical models
to predict prostate cancer incidence rates and related deaths from 2013 to 2025. Their findings indicated that
discontinuing PSA screening altogether would result in a 13 to 20 percent increase in prostate cancer mortality
(an additional 36,000 to 57,000 deaths in the U.S.) compared with continuing PSA screening during this
There are many different ways to use
the PSA test for screening, however.
“We feel more nuanced guidelines are
more appropriate,” said senior co-author Dr. Ruth Etzioni, a biostatistician in the Public Health Sciences
Division at Fred Hutch. The research showed that stopping screening at age 70 (age-restricted screening) is a
better option that would reduce the number of men who receive unnecessary treatment while preventing most of the
additional deaths that would come from discontinued screening.
The problem of
According to the National Cancer
Institute, most prostate cancers diagnosed in the United States are found through screening rather than a
patient reporting disease symptoms. Unfortunately, PSA screening is known to lead to large numbers of
overdiagnosed cases – situations in which the cancer that is found would not cause symptoms or death within a
man’s natural lifetime.
Treating overdiagnosed cancers tips off
a domino effect of harms, said Fred Hutch biostatistician Roman Gulati, the lead author of the
“Overdiagnosis causes anxiety for
patients and families, imposes an unnecessary economic burden on individuals and misuses health care resources,”
he said. In addition, surgery and radiation deliver a high risk for erectile, urinary and bowel dysfunction.
“Treating a cancer that is not destined to grow or present problems cannot improve quality of life for an
individual,” Gulati said.
Discontinuing screening altogether
would clearly eliminate 100 percent of all overdiagnosed cases. But stopping screening would also more than
double the number of prostate cancers that had already advanced, or metastasized, by the time they were
“Intensely and aggressively screening
would be associated with more lifesaving [than discontinuing all screening],” said Gulati, “but more men would
also be overdiagnosed. In this study, we also consider the middle ground, which provides a much more favorable
The risk for prostate cancer metastasis
depends on age, time since disease onset, and markers of aggressiveness such as tumor stage and grade. The
researchers noted that most prostate cancers are found in older men who show low-risk characteristics, and the
Prostate Cancer Foundation confirms that more than 65 percent of prostate cancers are found in men older than
65. However, older men are also much more likely to be overdiagnosed.
In the new study, the researchers used
two independently designed models to examine the effects of continued, age-restricted and discontinued PSA
screening from 2013 through 2025. The models synthesized data to represent prostate cancer progression,
detection, treatment and survival. The models used in the study were developed at the University of Michigan and
Fred Hutch to investigate national prostate cancer trends.
The models predicted that mortality
rates will rise with both age-restricted and discontinued PSA screening, but that additional deaths will
increase significantly more slowly under age-restricted versus discontinued screening (5 to 8 percent instead of
13 to 20 percent). PSA screening limited to men under age 70 could prevent a majority of the deaths that are
avoided with current screening while dramatically reducing the number of overdiagnoses.
“These tradeoffs underscore the
potential for smarter ways of using the PSA test,” Gulati said. “Restricting PSA testing to men under 70 years
of age is just one such approach. More generally, rather than discontinuing screening completely, our results
support developing more efficient ways to use the PSA test to screen for prostate
Lifestyle factors also play an
Despite the Task Force guidelines, said
Etzioni, the test is still available and being performed in healthy men. Many organizations, such as the
American Cancer Society, the American Urological Association and the American College of Physicians recommend
shared decision making about PSA screening for men under age 70 who can reasonably expect to live at least 10
“Patients need to know that screening
has potential benefits as well as potential harms,” said Etzioni, “and it has to be considered in the context of
a man’s lifestyle and any other conditions that may affect his health.”
While screening has its place, Etzioni
said boosting overall health through lifestyle factors such as not smoking, eating a healthy, balanced diet and
getting enough exercise can go a long way toward extending a man's life expectancy. For example, when it comes
to prostate cancer, research at Fred Hutch has found that obesity and long-term, heavy smoking significantly
increase the risk of an aggressive form of the disease. Hutch researchers also have found that moderate coffee
and red wine consumption and eating a diet rich in cruciferous vegetables may help prevent prostate
Regardless of whether PSA testing is
used for screening, the test remains an important tool for post-treatment monitoring of patients whose prostate
cancer has been confirmed by a biopsy.
Researchers from the University of
Michigan, University of Washington, National Cancer Institute and University of California, San Francisco,
collaborated on the study, which was funded by the NCI’s Cancer Intervention and Surveillance Modeling
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