By TARA PARKER-POPE New York Times
In a controversial finding that will affect at least 44 million American men, a government task force published its final recommendations against regular prostate cancer screening, concluding that the harms of the simple blood test far outweigh any potential benefit.
The recommendations, from the United States Preventive Services Task Force, offer the most detailed breakdown to date of the potential risks and benefits of the prostate specific antigen blood test, commonly known as the P.S.A. test. Most important, the task force found that, at best, one man in every 1,000 given the P.S.A. test may avoid death as a result of the screening, while another man for every 3,000 tested will die prematurely as a result of complications from prostate cancer treatment and dozens more will be seriously harmed.
Even so, the suggestion that men should give up annual prostate cancer screening has met with resistance, particularly from prostate cancer advocacy groups as well as some medical groups, including the American Urological Association.
Dr. Michael L. LeFevre, the co-vice chairman of the task force and professor of family and community medicine at the University of Missouri, said the recommendations, published online Monday in Annals of Internal Medicine, were based on the best scientific evidence available.
“Change is hard,” Dr. LeFevre said. “It’s hard for all of us, both within and outside the medical profession, to accept that not all cancers need to be detected or treated, and that there are harms associated with screening and not just benefits.”
Last fall, the task force shocked the men’s health community when it issued a draft recommendation against routine use of the P.S.A. test. The recommendations apply only to the routine screening of healthy men and do not affect men who seek medical advice about cancer symptoms. Currently, many men in their 40s, 50s and older receive annual P.S.A. screenings in hopes of detecting prostate cancer before symptoms appear. A high P.S.A. score, or a rising score over time, typically leads to a potentially painful biopsy in which a dozen or so tissue samples are taken to determine if cancer has begun to grow in a man’s prostate.
But for years, the scientific community has been concerned that widespread use of the test was harming far more men than it was helping. Prostate cancer is incredibly common, particularly in older men, and most of the time cancers found through screening tests are so slow-growing that they are unlikely to ever cause harm. The problem is that even with staging and grading of tissue samples, there is no way to know for sure which cancers detected through screening are likely to kill a man and which could be left untreated and unnoticed for decades.
Prostate biopsies can cause pain, infection and emotional distress, while a cancer diagnosis typically leads to surgery or radiation treatment that can render a man impotent or incontinent, or both. In rare cases, a man can die from complications of treatment. Although “watchful waiting” is an option for men with prostate cancer, the vast majority of patients who learn they have prostate cancer choose more aggressive treatment.
As a result, the task force weighed in, analyzing several large studies that tried to determine whether the potential benefits of prostate cancer screening outweighed the harms. Since the draft recommendations were issued last fall, additional data from the largest American and European P.S.A. screening trials have been published, giving the task force additional evidence on which to make its final recommendations.
The task force found that up to 43 men per 1,000 tested will face serious harms. Thirty to 40 men will develop incontinence or erectile dysfunction, or both, as a result of treatment. Two more men will have a serious cardiovascular event, like a heart attack, due to treatment, and one man will develop a life-threatening blood clot in his legs or lungs.
Even so, the American Urological Association issued a statement saying the group was “outraged” by the task force decision to finalize the recommendations. The group said the findings did not adequately reflect the benefits of P.S.A. testing and that it was “inappropriate and irresponsible” to issue a blanket statement against the testing.
Annals of Internal Medicine also published an accompanying article, in which the authors described themselves as “an ad hoc group including nationally recognized experts in the surgical and radiological treatment of prostate cancer, oncologists, preventive medicine specialists, and primary care physicians” who disagreed with the recommendations.
The group takes issue with the data that the task force used to formulate its decision, saying that it “overlooked or misinterpreted the impact of significant methodological flaws” in the research. Among other concerns, the group claimed that the task force failed to consider the needs of high-risk groups, and also claimed insurance companies were likely to refuse to reimburse for P.S.A. testing as a result of the task force guidelines.
“We suggest that physicians review the evidence for themselves, follow the continuing dialogue closely, and individualize prostate cancer screening decisions based on their patient preferences,” the group wrote.
Dr. LeFevre said that some men might look at the data on risks and benefits and decide that they still want to be tested, and nothing in the recommendations would prevent that. He also noted that federal legislation passed in the 1990s requires Medicare to cover the cost of P.S.A. testing, and that law will remain in effect unless Congress overturns it. Many insurance companies follow the lead of Medicare when it comes to reimbursement for health coverage.
For more information about the recommendations, go to the task force’s topic page on P.S.A. testing.