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Creighton Doctors Question Prostate Testing Recommendation

Four Creighton University physicians are questioning the U.S. Preventive Services Task Force (USPSTF) final recommendation for prostate cancer screening.

The task force’s recommendation against prostate-specific antigen or PSA testing for all men, regardless of age, is being published early online in the May 22 issue of Annals of Internal Medicine, a journal of the American College of Physicians.

However, an accompanying editorial, authored by Creighton physicians Marc Rendell (principle author), Sade Kosoko-Lasaki, Stephen Leslie and Henry Lynch and several others, argues that the task force, which does not include urologists or cancer specialists, largely bases its recommendations on flawed studies with inadequate follow-up time. In addition, the task force recommendations focus on mortality and do not take into consideration the substantial illness related to living with advanced cancer, the authors said.

Lynch, director of Creighton’s Hereditary Cancer Center and the holder of the Charles F. and Mary C. Heider Endowed Chair in Cancer Research, said the task force recommendations also leave out high-risk populations and younger men. He and the other authors expressed concern that the new recommendations will take Americans back to an era when prostate cancer was often discovered at advanced and incurable stages.

“The recommendations (of the task force) carry considerable weight with Medicare and other third-party insurers,” Lynch said. “My colleagues and I strongly believe that the task force recommendations should not be used as justification by insurers, including Medicare, to deny diagnosis of prostate cancer to the male population at risk.”

The task force last published recommendations regarding prostate cancer screenings in 2008. At the time, researchers concluded there was no evidence to support testing men over the age of 75 for PSA, a protein produced by the prostate gland that may be found in elevated levels in the blood when a prostate cancer or certain other prostate diseases are present.

In making its recommendation, task force members considered two major trials of PSA testing in asymptomatic men to assess the life-saving benefits of PSA testing.

They said there is strong evidence showing that PSA screening is associated with significant harms. Nearly 90 percent of men with PSA-detected prostate cancer undergo early treatment with surgery, radiation or androgen-deprivation therapy. Evidence shows that up to five in 1,000 men will die within one month of prostate cancer surgery and between 10 and 70 men will survive, but suffer life-long adverse effects such urinary incontinence, erectile dysfunction and bowel dysfunction, they said.

According to Otis W. Brawley, M.D., chief medical officer of the American Cancer Society, and author of a second accompanying commentary, over-diagnosis makes it appear that PSA screenings save lives when they do not. Many men are diagnosed with prostate cancer that may never have progressed within their lifetime, the commentary noted.

In October 2011, the task force posted its draft recommendations for public comment. While its final recommendation clearly states that physicians should not offer PSA screenings, the task force says it leaves the ultimate power in the hands of healthcare providers.

“The USPSTF recognizes that clinical, policy, and coverage decisions involve more considerations than evidence alone,” said task force chair Virginia Moyer, M.D. “Clinicians and healthcare providers should understand the evidence but individualize decision-making to the specific patient or situation.”

Lynch is an expert on hereditary prostate cancer. He has received a three-year, $731,278 grant from the U.S. Department of Defense to study the role heredity plays in prostate cancer among African Americans. Read more