Healthy Men Should Undergo Baseline PSA Screening: A Call for Clear Guidance
By: Bashir Al Hussein Al Awamlh, MD, Vanderbilt University Medical Center, Nashville, Tennessee; Jonathan Shoag, MD, Case Western Reserve University School of Medicine, Cleveland, Ohio, University Hospitals Cleveland Medical Center, Ohio | Posted on: 27 Jun 2023
PSA screening fell out of favor among physicians over the past decade. In large part, this was due to professional guidelines based on short-term results of trials, including faulty data from the PLCO (Prostate, Lung, Colorectal, and Ovarian) Cancer Screening Trial. The subsequent realization that the vast majority of men in the control arm of the PLCO Trial had PSA testing, negating its conclusions,1 the accrual of longer-term data from European Randomized Study of Screening for Prostate Cancer (ERSPC) sites, as well as modeling studies based on randomized and epidemiological data all increasingly suggest the benefits of screening outweigh its harms.2
Despite this increasingly clear evidence, screening rates have not recovered. For instance, one recent Veterans Health Administration study found that 37% of men were screened in 2019, as compared to ∼50% prior to 2012.3 Further, more prostate cancers are being diagnosed at higher grades and stages, with mortality now potentially increasing, reversing decades of progress resultant from screening.4 As professional societies, including the AUA, the American Cancer Society, and the United States Preventive Services Task Force, gear up for another round of guideline updates, we believe clear guidance from these organizations is critical.
While continuous efforts to improve shared decision-making in prostate cancer screening are valued, data suggest that real shared decision-making and the use of decision aids are challenging to implement and are almost certainly not being performed adequately, with a minority of men reporting shared decision-making, despite years of utilization of such language by guideline panels.5-7 In our view, this focus on providing tools for discussion, rather than issuing clear guidance regarding screening, is a disservice to patients and their doctors. A guidelines panel’s goal should be to issue clear guidance based on expert assessment. Such clarity is desperately needed, as a generation of primary care physicians were trained not to perform PSA screening and, at best, consider screening controversial.
In our view, it is now clear that PSA screening, as an initial triage test to assess prostate cancer risk, is beneficial for otherwise healthy men beginning in their 40s or early 50s. This is based on the observed time-dependent increase in the benefits of screening, which were not incorporated in prior guidelines. To illustrate this point, imagine an extreme example—examining the tradeoffs of screening 1 year after beginning a screening program. Obviously, there would be substantial harm from treatment, such as impotence and incontinence, and no mortality benefit because no patient with lethal cancer will be cured by local therapy within 1 year. While it should be obvious that 1 year from screening is too short an interval, policy makers arbitrarily selected intervals of 9 or 13 years to examine the tradeoffs of screening, which is also too short, as many men begin screening in their 50s, and the harms of prostate cancer metastasis and death often don’t present until men are in their 70s or 80s.
When the long-term tradeoffs of PSA screening are modeled,2 even using very conservative assumptions, we found that the number of excess diagnoses to prevent 1 prostate cancer death at 25 years was 11, with estimates well into the single digits depending on model parameters. This is consistent with longer-term data from the ERSPC as well as recent reports from ERSPC sites with longer follow-up.8,9 Importantly, these numbers are comparable to the number needed to treat to cause 1 case of urinary incontinence or impotence from prostate cancer treatments.2,10,11 Although a simplification, if the tradeoffs of screening approximate 1 case of impotence or incontinence to prevent 1 death from prostate cancer, to say nothing of those whose metastatic disease is prevented, in our view, the benefits of screening clearly outweigh its harms. Recent work suggests that for Black men, or other men at high risk, these tradeoffs are almost certainly even more favorable.12
Based on these observations and the recent improvements in prostate cancer screening and diagnostics, including the potential use of MRI as a triage test and active surveillance for indolent cancer, it is our opinion that PSA screening be recommended for all healthy men. The focus on optimizing screening with complex algorithms and flowcharts, while well intentioned, misses the reality that many patients, including men at high risk who stand to benefit most, are not undergoing screening at all. A straightforward message and clear guidance are needed from expert panels in this regard.
- Shoag JE, Mittal S, Hu JC. Reevaluating PSA testing rates in the PLCO trial. N Engl J Med. 2016;374(18):1795-1796.
- Shoag JE, Nyame YA, Gulati R, Etzioni R, Hu JC. Reconsidering the trade-offs of prostate cancer screening. N Engl J Med. 2020;382(25):2465-2468.
- Bryant AK, Lee KM, Alba PR, et al. Association of prostate-specific antigen screening rates with subsequent metastatic prostate cancer incidence at US Veterans Health Administration facilities. JAMA Oncol. 2022;8(12):1747-1755.
- Siegel RL, Miller KD, Wagle NS, Jemal A. Cancer statistics, 2023. CA Cancer J Clin. 2023;73(1):17-48.
- Légaré F, Ratte S, Gravel K, Graham ID. Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals’ perceptions. Patient Educ Couns. 2008;73(3):526-535.
- Riikonen JM, Guyatt GH, Kilpelainen TP, et al. Decision aids for prostate cancer screening choice: a systematic review and meta-analysis. JAMA Intern Med. 2019;179(8):1072-1082.
- Jiang C, Fedewa SA, Wen Y, Jemal A, Han X. Shared decision making and prostate-specific antigen based prostate cancer screening following the 2018 update of USPSTF screening guideline. Prostate Cancer Prostatic Dis. 2021;24(1):77-80.
- Hugosson J, Roobol MJ, Mansson M, et al. A 16-yr follow-up of the European Randomized Study of Screening for Prostate Cancer. Eur Urol. 2019;76(1):43-51.
- Frånlund M, Månsson M, Godtman RA, et al. Results from 22 years of followup in the Göteborg Randomized Population-based Prostate Cancer Screening Trial. J Urol. 2022;208(2):292-300.
- Donovan JL, Hamdy FC, Lane JA, et al. Patient-reported outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med. 2016;375(15):1425-1437.
- Donovan JL, Hamdy FC, Lane JA, et al. Patient-reported outcomes 12 years after localized prostate cancer treatment. NEJM Evid. 2023;10.1056/EVIDoa2300018.
- Basourakos SP, Gulati R, Vince RA Jr, et al. Harm-to-benefit of three decades of prostate cancer screening in Black men. NEJM Evid. 2022;10.1056/evidoa2200031.