Moulay Idris, Morocco - photo by JoAnn SturmanDr. Rahman practices urology in Fresno, California. He is a graduate of Duke Medical School and completed his urology residence training at the University of California San Francisco. He has written and lectured both in the United States and internationally on prostate cancer. Recently, he was awarded the Robert Krane Prize in Urology by the British Journal of Urology for the top research paper. He is a nationally known expert in robotic urological surgery.
Next week, the U.S. Preventive Services Task Force (USPSTF) will release new draft recommendations regarding prostate-specific antigen (PSA) testing, recommending against the use of the test in men under age 75. As a practicing urologist who has seen the devastating effects of prostate cancer, I have to disagree with this assertion and am concerned that the Tasks Force's recommendation will ultimately do more harm than good for many men at risk for developing prostate cancer.
The Task Force quoted two studies (American and European) published in 2009 to support their statement of PSA screening, "that if any benefit does exist, it is very small after 10 years." Yet the task force did not comment on studies published within the past year that re-analyzed both of these same studies for patients with longer follow up and in younger patients. In the American study (the PLCO trial), an analysis was performed on patients that were younger and had fewer medical problems. This study found a 44% reduction in prostate cancer specific mortality - i.e. PSA screening of younger and healthier men actually saved lives. Similarly, in the European study, a subset analysis of this trial called the Goteborg trial looked at PSA screening in younger men with longer follow up (14 years compared to nine years that had been previously published). This study also concluded that PSA screening cut prostate cancer specific mortality by almost 50%. Further, they found to save one life, 293 men would need to be screened and twelve prostate cancer patients had to be diagnosed, not necessarily treated (many men in this study were not treated after their diagnosis). These studies are convincing and tell us that PSA screening has the most benefit in younger and healthier patients where prostate cancer may eventually effect their life and longevity.
Prostate cancer is not a monolithic disease process and a wide variability of aggressiveness is seen. We know that there are limited and poor choices for treating locally advanced or metastatic prostate cancer. In fact, the five year survival rate for patients in this category is less than 30%. For these patients to have excellent outcomes, there must be early detection and treatment must occur while the cancer is localized to the prostate. For these localized prostate cancers, not all will require active treatment as not all prostate cancers are life threatening. The decision for treatment is one that men should discuss in detail with their urologists. The doctor and patient must determine whether active treatment is necessary, or whether surveillance is an option for the patient's specific prostate cancer.
We have seen a dramatic change in the presentation of prostate cancer since the widespread use of PSA screening or "the PSA era"as it is often called. With this, we have seen a nearly 40% reduction in prostate cancer specific mortality. As long as I continue to see the benefits of PSA screening in my medical practice, I will continue to advise my patients that when interpreted appropriately, the PSA test provides important information in the diagnosis, pre-treatment, risk assessment and monitoring of prostate cancer patients. By maligning the PSA test before a suitable alternative has been approved or available, does a great disservice to all men worldwide who may benefit from early prostate cancer detection.
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