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When Is Screening Excessive? Researchers Offer Some Practical Advice Amidst PSA Controversy
By Rachel Pomerance
SAN FRANCISCO —The American Board of Internal Medicine, together with Consumer Reports, recently launched a public education campaign called “Choosing Wisely” to cut down on excessive medical procedures that might do patients more harm than good.
The initiative aims to improve U.S. healthcare by encouraging physicians and patients to consider more carefully the value of various procedures; toward that end, the internal medicine group has furnished lists from specialty societies that have each identified courses of care worth questioning.
Louise C. Walter, MD, Photo from UCSF Press Release
That prostate-specific antigen (PSA) screening and consequent treatments surface on these warning lists should come as no surprise to those working in the detection and treatment of prostate cancer. In fact, it’s only the latest development in the increasing controversy surrounding when and for whom PSA testing makes sense.
“You can’t just consider it a blood test in isolation,” said Louise Walter, MD, a geriatrician at the San Francisco Veterans Affairs Medical Center. That’s due to what comes next — the common findings of elevated PSA levels that can lead to procedures fraught with risks. Among them are impotence, incontinence and bowel problems, not to mention psychological distress. Meanwhile, as practitioners well know, neither does an elevated PSA level necessarily indicate cancer or a low PSA level guarantee against it.
Research published by Walters last December in the Journal of General Internal Medicine found that hospitals screen elderly men with limited life expectancies for prostate cancer at surprisingly high rates, even though guidelines recommend against such screening. That study involved 622,262 men at 104 VA medical centers.1
A study published in February in the Journal of the National Cancer Institute, however, found that PSA testing declined in the VA’s Pacific Northwest Network 3 percentage points among men aged 40-54; 2.7 percentage points among those aged 55-74; and 2.2 percentage points among men aged 75 years and older. The authors suggested that the decline was due to the new guidelines and clinical trial results.2
As questions around PSA testing continue, how should VA providers answer the big one: When is it warranted?
Until a more effective test becomes available, experts said the best course of action is a thoughtful and informed conversation between patients and their physicians, as well as keeping in mind the needs of certain populations. Additional vigilance should be exercisd with high-risk groups such as African-Americans and/orthose with a first-degree relative with prostate cancer. Given the slow rate at which prostate cancer typically progresses, PSA testing typically is not advised for elderly patients, for whom more pressing issues are often at stake.
For Walter’s patients, who are over the age of 75, PSA testing likely distracts from their care, she said, and creates serious risks for people who lack the longevity to see any benefits.
In the fall of 2011, the U.S. Preventive Services Task Force, a federal agency in Rockville, MD, whose guidelines are typically followed by the VA, recommended against PSA testing for men ages 75 and older; it found evidence too inconclusive to endorse screening for men under the age of 75. That decision was informed by U.S. and European trials that showed conflicting results, with the former finding no advantage and the latter indicating a degree of benefit.
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