Prostate Cancer Screening via PSA Levels May Not Be Routinely Advisable Except in Higher Risk Patients

© 2010 Peter Free

 

15 September 2010

 

PSA screening for prostate cancer in normal risk patients may be a waste of money and increase overtreatment and associated harms

 

The British Medical Journal just published two analyses that take critical looks at the common practice of screening for prostate cancer via measuring prostate specific antigen (PSA) in the blood.

 

The first of these was a meta-analysis of six randomized controlled trials involving 387,286 patients.  It concluded that:

 

There was no significant effect of screening on death from prostate cancer . . . or overall mortality.

 

The existing evidence from randomised controlled trials does not support the routine use of screening for prostate cancer with prostate specific antigen with or without digital rectal examination.

 

© 2010 Philipp Dahm et al., Screening for prostate cancer: systematic review and meta-analysis of randomised controlled trial, BMJ 2010;341:c4543

 

White males, aged 60, with low levels of PSA should probably not be PSA-screened regularly

 

The second British Medical Journal analysis looked at 1167 Swedish men in the Malmo Preventive Study.

 

Aged 60 in 1981, these men were followed to age 85.  Researchers looked for metastasis or death from prostate cancer.

 

The study concluded:

 

The concentration of prostate specific antigen at age 60 predicts lifetime risk of metastasis or death from prostate cancer.

 

Though men aged 60 with below the median (less than or equal to 1 ng/ml) might harbour prostate cancer, it is unlikely to become life threatening.

 

Such men could be exempted from further screening, which should instead focus on men with higher concentrations.

 

© 2010 Hans Lilja et al., Prostate specific antigen concentration at age 60 and death or metastasis from prostate cancer: case-control study, BMJ 2010;341:c4521 (paragraph split for online readability)

 

A British Medical Journal editorial put PSA screening in perspective ─ evaluate risk for cancer first

 

For now, clinicians are best advised to individualise their approach to PSA based screening.

 

Young men at high risk of prostate cancer, such as those with a strong family history and higher baseline PSA concentrations, should be followed closely and could also be considered for “risk reduction” approaches with 5α reductase inhibitors or dietary and lifestyle modifications (or both).

 

Conversely, elderly men and those with a low risk of disease could be tested less often, if at all.

 

© 2010 Gerald L. Andriole Jr., Screening for prostate cancer, BMJ 2010;341:c4538 (paragraph split for online readability)

 

On a side note ─ risks and costs of overtreatment are rarely examined

 

My wife recently conducted a literature review of mammographic screening in women aged 40 and older.  She noticed that research is virtually entirely lacking regarding the financial, psychological, and physical costs to following up false positives.

 

My impression of PSA testing (since the mid-1990s) is the same.

 

The medical community and its associated industries have a very significant financial stake in testing, even if it costs patients unnecessary harms.

 

Similarly, patients who are frightened of cancer tend to underestimate the ultimate costs related to what turns out to be unnecessary and sometimes harmful treatment.

 

American society would benefit from significantly more medical cost-benefit research and analyses

 

There is little systemic motivation to undertake intelligent cost-benefit analyses of American medical screening and intervention protocols.  Virtually all society-wide analysis of medical interventions comes from European-collected data.

 

The absence of scientific information regarding medical efficacy in the United States contributes to the economic burden that unproven and uninvestigated medical practices place on American society.

 

In the larger picture ─ rampant medical costs harm American citizens and American business in the global economy

 

Unnecessary medical screening and interventions are just another subtle area in which America’s self-serving establishment plutocracy deceives the unconcerned public into going along for a questionable ride.

 

Our public appears to have bought the idea that small and medium-sized business owners have the responsibility to provide health insurance.  The “business as insurance provider” infrastructural trait can be attributed to the evolution of health insurance in the United States.

 

As a result, business indirectly bears the excessive medical costs that our incurious culture assumes, without evidence, are necessary.

 

Burdening the proportionately small entrepreneurial segment of our society with the financial costs of providing health protection for the entirety is an economically dumb and ethically inequitable way to burden American business in a global economy.

 

Only the health plutocracy benefits from this irrational system.

 

More genuinely productive elements of the American economy suffer.

 

This is a curious way to run the ship of state.

 

Given the disparity in political and oligarchical power between the health plutocracy, on the one hand, and small and medium-sized business, on the other ─ the situation is unlikely to change.

 

How did PSA screening wind up as a plutocracy talk?

 

Both start with the letter “p”.

 

But there is a real connection.  You just have to think a bit to see it.