Ask the Urologist: What You Need to Know about PSA and the Increase of Metastatic Prostate Cancer in the US

Posted on: August 19, 2016

By Dr. Warren Bromberg  

In 2012, the US Preventative Services Task Force (USPSTF) stunned the medical and lay community with its recommendation against routine prostate-specific antigen tests or, PSA screenings, for prostate cancer. This screening can detect high levels of PSA that may indicate the presence of prostate cancer. The Task Force gave PSA screening a grade of “D” primarily based on the results of the Prostate, Lung, Colorectal, and Ovary (PCLO) trial, reported in 2009, which showed no difference in prostate cancer incidence or mortality between the screening and control groups after 7 years. Since this seminal declaration, screening has decreased from 33% to 18.7% in men aged 55-69 years, the age range generally thought to be most critical in identifying and treating the second-leading cause of cancer death in men.

Bromberg, (Warren Bromberg, MD) MKMG_Sept 2015Recently however, a follow-up survey administered to patients in the PCLO trial has revealed that more than 80% of the control group had at least 1 PSA test during the trial and more than half had PSA assessments within a year before enrollment. In fact, as the trial progressed to its 13 year mark, it appears that men in the control group had more PSA testing than those in the intervention arm. This so-called “contamination” renders the landmark PCLO trial meaningless.

With this new information the USPSTF plans to update its recommendation and the Centers of Medicare and Medicaid Services (CMS) has suspended its plans to discourage PSA testing in all men.

Now, on top of this, along comes a publication from the medical centers at Northwestern and the University of Chicago, which analyzed data on 767,550 men with prostate cancer reported from 1,089 US health care facilities and found that not only did the incidence of metastatic prostate cancer rise from 2007 to 2013, but it is 72% higher than in 2004. The largest increase was in men aged 55 to 69 years, those thought to benefit most from screening and treatment. Of additional concern, highlighted in the article, is that the number of men over age 65 is expected to double by the 2050. The need to treat and care for greater numbers of men with metastatic prostate cancer will substantially burden our health care economy.

The exact reason for the rise in metastatic cancer over the past decade, the authors conclude, is not clear. However, taken together, the trend towards less testing in the cohort of men who may benefit most and the recent rise in metastatic prostate cancer, the authors of the study appropriately make the case for continued efforts to better identify men at greatest risk and for improved therapies for men with advanced disease. Any new recommendations proffered by the USPSTF are likely, once again, to have profound implications on policy.

Editor’s note: Warren Bromberg, MD, FACS, is the Chief of the Division of Urology and Co-Director of the Institute for Robotic and Minimally Invasive Surgery at Northern Westchester Hospital.