Government task force discourages routine testing for prostate cancer
By Brian Vastag,
Men should no longer receive a routine blood test to check for prostate cancer because the test does more harm than good, a top-level government task force has concluded in a final recommendation that immediately became controversial.
The recommendation from the U.S. Preventive Services Task Force runs counter to two decades of medical practice in which many primary-care physicians give the prostate-specific antigen (PSA) test to healthy middle-aged men.
But after reviewing the available scientific evidence, the task force concluded that such testing will help save the life of just one in 1,000 men. At the same time, the test steers many more men who would never die of prostate cancer toward unnecessary surgery, radiation and chemotherapy, the panel concluded.
For every man whose life is saved by PSA testing, another one will develop a dangerous blood clot, two will have heart attacks, and 40 will become impotent or incontinent because of unnecessary treatment, the task force said in a statement Monday.
Many middle-aged men regularly get the PSA test. But for years, some experts have questioned whether such screening saves lives. Monday’s statement finalizes a draft recommendation made by the task force last fall.
While not mandates, the group’s statements have widespread impact, especially on private insurers and Medicare.
The recommendation raises the question of whether a test deeply embedded in the medical landscape can be pulled back.
“It’s a tough message,” said Virginia Moyer, chairman of the task force and a professor of pediatrics at the Baylor College of Medicine in Houston. “Nothing would have made us happier than to have found that [routine PSA screening] really works.”
Moyer added that men who have urinary symptoms — such as pain or difficulty urinating — may still benefit from PSA testing.
“Our recommendation is not a recommendation to tell the patient to shut up and go away if they ask about” PSA testing, Moyer said. “Our recommendation is that it not be routinely offered.”
Officials at two large insurers said the companies are unlikely to cease coverage in the near future. Lori McLaughlin, a spokeswoman for WellPoint, said the company “considers continued screening for prostate cancer as medically necessary for men between the ages of 50 and 75” but will continue to review the evidence.
Tammy Arnold, a spokeswoman for Aetna, which considers PSA screening a medically necessary preventive service for men age 40 and older, said officials there will review their policies.
Specialists who diagnose and treat prostate cancer reacted swiftly. The American Urological Association said it was “outraged” by the recommendation. “Men who are in good health and have more than a 10-15 year life expectancy should have the choice to be tested and not discouraged from doing so,” the group said in a statement.
The Large Urology Group Practice Association, which represents 1,800 urologists, issued a statement saying it was “appalled” and called the recommendation “irresponsible and inexplicable.”
Any man worried about prostate cancer should discuss the risks and benefits with his physician, said Moyer, a message that the American Cancer Society has been pushing since 1997.
Alexander Chester, a primary-care physician in the District, said he explains the risks of unnecessary injury before offering PSA tests. “But half the people still want it,” he said. “It will take a long time to get it out of the popular culture.”
In the District, which has the highest incidence and highest death rate of prostate cancer in the country, some doctors said they will continue to rely on the test, especially when screening black men, who have higher rates of prostate cancer than white men.
“We will recommend it in the black population because of the amount of cases that we see that are requiring treatment and not active surveillance,” said Oscar Streeter, a radiation oncologist at Howard University.
The reaction from physicians who say prostate cancer is overdiagnosed was positive.
“This recommendation is a huge win for men,” said Georgetown University’s Kenneth W. Lin, who has studied PSA screening. “Can you imagine performing mammograms regularly on women without first collecting scientific evidence that they save lives?”
Otis Brawley, chief medical officer of the American Cancer Society, commended the task force for “taking a really hard line here.”
Brawley said that PSA testing has become “big, big money,” with testing companies, physicians and hospitals all profiting.
PSA tests do not directly detect cancer — they detect a protein made by the prostate. Conditions other than cancer, including benign growth of the prostate, can raise PSA readings, leading to painful biopsies and other tests.
The Food and Drug Administration has never approved PSA testing for the general population. Instead, the agency in 1986 allowed the test to be used to evaluate men who have urinary symptoms. But physicians are free to use the test however they choose, and a huge industry quickly sprang up that promoted the tests to healthy men.
Until recently, no large, high-quality study had looked at whether widespread, routine PSA testing saved lives. In 2009, that changed when results from two studies, in the United States and Europe, generally found that it did not. In the European study, there was some hint of a benefit in two of seven countries, in men 55 to 69, Moyer said.
Brawley said PSA testing now joins the ranks of other medical procedures that proved to be ineffective after widespread adoption. In the 1960s, chest X-rays were used to diagnose lung cancer, but a large study in the 1970s found they led to overdiagnosis. In the 1990s, many women with breast cancer were offered an extreme treatment — bone marrow transplants — before a study found that the treatments were not saving lives.
“Medicine has made all these mistakes, and in prostate cancer this has been a very lucrative business for the last 20 years,” Brawley said.
Prostate cancer is the second most common cancer in men, after skin cancer. About 242,000 cases are diagnosed each year in the United States, with about 28,170 men dying of the disease. Most cases do not lead to death, because many of the cancers are slow-growing and not life threatening.The 16-member task force, made up of independent experts, is organized by the Department of Health and Human Services to assess preventive medical care. The group’s influence was enhanced by the 2010 federal health-care law, which will base some of its requirements for coverage on the group’s ratings.
Staff writers N.C. Aizenman and Lena H. Sun contributed to this report.