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Urologists no longer support routine prostate-cancer screening

Crystallographic structure of human prostate-specific antigen
(green/gold cartoon)

In a surprising turnabout, the American Urological Association (AUA) has announced that it is no longer recommending that men undergo routine prostate-specific antigen (PSA) screening.

Its new draft guidelines, released at the AUA’s annual meeting in San Diego, Calif., on Friday, state that asymptomatic men under age 55 or over age 69 who are at average risk for the disease do not need to be screened at all. As for average-risk men between the ages of 55 and 69 years, the AUA guidelines recommend that they carefully discuss the risks as well as the benefits of the PSA screening with their doctor before having it done. Furthermore, if they do decide on screening, an interval of every two to four years is probably preferable to annual testing.

Men at higher risk of prostate cancer — African-Americans, for example, and those with a strong family history of the disease — may benefit from more routine screening, the guidelines add.

These new recommendations bring the AUA closer to agreeing with those issued by several other medical organizations, particularly the U.S. Preventive Services Task Force (USPSTF). In 2011, amid considerable controversy — much of it stirred up by the AUA — the independent panel of experts that make up the USPSTF said the scientific evidence overwhelmingly shows that the harms of routine PSA testing outweigh any possible benefits.

Some research suggests that for men aged 55 to 69, routine screening may prevent up to one cancer death for every 1,000 men screened over a decade. But many more men will be harmed by routine screening — up to 47 for each life saved, according to one study. Those harms include bleeding and infection (including serious ones) from the biopsies that are done when an elevated PSA level is detected, as well as unnecessary treatments for slow-growing cancers that are non-life-threatening. Such treatments often lead to incontinence and impotence.

Seeking middle ground

The AUA had been one of the USPSTF’s loudest critics.

“We are concerned that the Task Force’s recommendation will ultimately do more harm than good to the many men at risk for prostate cancer, both here in the United States and around the world,” then-AUA President Dr. Sushil S. Lacy said in a statement at the time the USPSTF recommendations went public.

The AUA actively urged its members to write letters to newspapers and Congress about how the USPSTF was doing “a great disservice by discouraging the use of the test.”

The patient-advocacy group Zero: The Project to End Prostate Cancer, co-founded by the AUA (and funded by drug and medical-device manufacturers), was even more strident in its condemnation of the USPSTF guidelines. One of its officials warned that the end to routine PSA screening “condemns tens of thousands of men to die this year and every year going forward.”

As the New York Times points out in its article about the new AUA guidelines, “Some experts skeptical of screening have noted that the advent of P.S.A. testing led to a big jump in the number of diagnoses of prostate cancer, increasing the business of urologists. The P.S.A. test underpins a prostate cancer industry, consisting of laboratories that do biopsies, manufacturers of surgical robots and radiation equipment, even suppliers of adult diapers.”

Not exactly neutral

The AUA’s new PSA-screening recommendations do not go as far as the USPSTF’s guidelines. They encourage men between the ages of 55 and 69 to talk with their physicians about routine screening. Just how neutral a discussion that will be is not clear, particularly if the men are having the discussion with a urologist.

A survey taken after the USPSTF’s recommendations went public found that urologists continued to believe, in overwhelming numbers, that routine PSA testing was necessary for men age 50 and older. 

Still, the AUA’s new guidelines are welcomed news for health officials who’ve been campaigning for a more evidence-based approach to PSA screening. One of those officials is Dr. Otis Brawley, the American Cancer Society’s chief medical officer and a long-time critic of routine PSA testing. 

“I believe that the American Urological Association should be commended for a very careful evidentiary review and developing a statement that is truly consistent with the state of the science,” he told NPR reporter Scott Hensley in an e-mail. “The past 20 years represents some of the worst in public health in that we widely disseminated a screening intervention before adequately assessing it. I welcome any effort to explain to men the uncertainty, potential harms, and potential benefits of PSA screening.”

You can read the press release about the AUA’s new draft guidelines here.

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