Advanced Prostate Cancer Cases Are Rising: Are PSA Screening Standards to Blame?

  • Changing guidelines have led to a reduction in prostate-specific antigen (PSA) testing for prostate cancer.
  • This blood-testing method can lead to unnecessary treatment, but experts say it is still a powerful tool in detecting early cases of the disease.
  • They say the guidelines have led to more cases of advanced prostate cancer and fewer cases of early stage prostate cancer.
  • Experts say that PSA testing is effective, and early diagnosis should be treated with active surveillance rather than unnecessary treatments and biopsies.

A new study shows that cases of advanced prostate cancer in the United States are on the rise while cases of early stage prostate cancer are declining.

The study appeared in the Journal of the National Cancer Institute and was authored by researchers from the American Cancer Society.

Researchers say the seemingly paradoxical figures are likely due to the changing landscape of screening and testing over the past 2 decades.

In essence, researchers say, earlier cases of prostate cancer aren’t being detected due to fewer screenings. Those cases are then discovered when they advance to a later stage.

Prostate cancer is the second most common cancer among men in the United States, so experts say the study emphasizes the importance of public education in preventing the disease.

History lesson

To understand why the messages surrounding prostate cancer screening have changed so much, it’s important to know the history.

Dr Gary Kirsh, president of The Urology Group, told Healthline that a specific type of screening — prostate-specific antigen (PSA) screening performed via a blood test — has been at the center of the medical debate.

“In the early days of PSA testing, there was a lot of cancer found that hadn’t been found previously, and there was a lot of treatment for early cancer that hadn’t been done previously,” Kirsh explained. “As a result of that treatment, there were some side effects to those treatments that men didn’t experience in that many numbers previously.”

At this point, the United States Preventive Services Task Force (USPSTF) — a panel of experts that develops recommendations for doctors — took note of the PSA screening method.

The USPSTF determined that the benefits didn’t outweigh the risks and in 2008 recommended against PSA screening for men 75 and older.

In 2012, the task force revised this restriction to include all men.

Finally in 2018, the guidelines were changed once more to recommend against PSA screening for men aged 70 and up.

Kirsh explained that there’s some merit to the decision-making as PSA testing may diagnose early stage cases of the disease, potentially prompting unnecessary treatments and biopsies.

“The problem with that kind of thinking, while it has some truth, is that it did not recognize doctors’ ability to change and understand the use of the test over time,” he said. “So what happened was that the USPSTF threw the baby out with the bathwater. Years later, the chickens have come home to roost, and we’re now beginning to document a shift in the amount of diseases preventing in a noncurable state.”

As a result of the changing guidelines, PSA testing rates declined.

According to Ahmedin Jemal, DVM, PhD, lead author of the study and scientific vice president for surveillance and health services at the American Cancer Society, there has been a potentially deadly trade-off in recent years.

“These data illustrate the trade-off between higher screening rates and more early stage disease diagnoses (possibly overdiagnosis and overtreatment) and lower screening rates and more late stage (possibly fatal) disease,” Dr. Jemal wrote in the study.

Kirsh says the USPSTF’s changing guidelines caused many doctors to eliminate a perfectly good method for detecting early cases of prostate cancer.

Early detection still critical

While overdiagnosis has been a top-of-mind concern for the USPSTF panel, experts say PSA testing is still critical in detecting early cases of the disease.

“It’s a test that has to be used with wisdom, and the wisdom is that everyone with an elevated PSA doesn’t need to be biopsied, and, more importantly, everyone with a small amount of early, nonaggressive prostate cancer doesn’t need to be treated,” explained Kirsh.

“Detecting cancer before it spreads can mean the difference between curable and incurable, life or death,” explained Jamie Bearse, chief executive officer and president of ZERO – The End of Prostate Cancer. “The PSA test is similar to a pap smear for women in detecting cervical cancer in that it has a fair amount of false positives and false negatives. Still, the PSA test is safe and the only first effective step to detect prostate cancer.”

Steven Eisenberg, DO, a California oncologist who specializes in prostate cancer, told Healthline that the potential risks of PSA testing don’t negate its positives.

“There have been concerns of overtreatment of early stage prostate cancer,” he said. “However, when screening is diminished, we are catching fewer cases in the earliest stage. True, fewer early diagnosed cases would prevent overtreatment. However, a higher percentage of men would be expected to present in a more advanced stage.”

To bridge the divide between overtreatment and potentially missing a diagnosis, Eisenberg favors a measured approach.

“In my opinion, thoughtful communication and an individualized approach is best,” he said. “For example, men who are screened and diagnosed with early stage, less aggressive disease based on several factors can be followed closely utilizing active surveillance.”

Where do we go from here?

Kirsh emphasizes that the USPSTF guidelines were a good faith effort by the experts on the task force but were ultimately misguided.

Now, with several years of data, he said it’s possible to quantify the damage done.

However, the toothpaste can’t be put back in the tube at this point, and the medical community will have to correct for the damage as it moves forward, he said.

“Really, the only thing we can do is public education, and this new study, along with others, is important,” said Kirsh. “We need to get the word out about what has happened over the last decade to get the attention of the public and physicians.”

Eisenberg says patients and doctors need to form a “powerful partnership,” one with open dialogue pertaining to the relevant issues.

“The big issue is the need for conversations covering individualized intelligent screening,” he said. “These talks should commence at age 50 for most men. For individuals with a family history, or are African American, the conversation should begin earlier, at age 40.”

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