Update on Prostate Cancer Screening with PSA

Alvin B. Lin, MD, FAAFP
 
Dr. Lin is an associate professor of family and community medicine at University of Nevada School of Medicine and an adjunct professor of family medicine and geriatrics at Touro University Nevada College of Medicine. He also serves as an advisory medical director for Infinity Hospice Care and as medical director of Lions HealthFirst Foundation. Dr. Lin maintains a small private practice in Las Vegas, NV. The posts represent the views of Dr. Lin, and in no way are to be construed as representative of the above listed organizations. Dr. Lin blogs about current medical literature and news athttp://alvinblin.blogspot.com/.

Quantity vs. quality: which would you choose? In an ideal situation, both, right? But in the real world, we often have to pick one over the other. Worse, we don't have ideal data so we're left with an imperfect decision making process. A good example of this is prostate cancer screening with prostate-specific antigen (PSA). 

As you know by now, the US Preventive Services Task Force (USPSTF) recently recommended against screening for prostate cancer with PSA, giving this a D Grade, as there was no proof of any reduction in all-cause mortality. Within the last month, another study suggested that not screening with PSA would lead to a tripling of men presenting with metastatic disease, assuming the same rate as in the pre-PSA era. But on the other hand, there was no mention of all-cause mortality. As a corollary, another study concluded that treatment of localized low grade prostate cancer via radical prostatectomy did not improve all-cause mortality.

So what do we do? The authors of a new analysis of the European Randomized Study of Prostate Cancer (ERSPC) published August 16, 2012, in the New England Journal of Medicine concluded that quality of life from PSA screening would be affected by one's interpretation of risk & benefit. In fact, the number of quality-adjusted life years (QALY) gained or lost depended upon the patient's point of view. In other words, those who value quantity over quality want to prevent cancer at any cost and would tolerate complications much more so than those who relished quality of life over quantity.

The editorialist for this study recommends an in-depth conversation with the patient to help in the decision making process. But how realistic is this in a 5 to 10 minute appointment? A case studywas presented in a third article pitting one physician against another regarding the utility and benefit of PSA screening. 

In the end, the real solution is to find a more sensitive and more specific test to use for prostate cancer screening. And while we're at it, we also need to reform our health care system so that we provide quality care rather than quantity care.