Prostate Cancer Screening | Dr. Jeannette Potts | Vista Urology Visits

Prostate Cancer Screening: Ineffective & Overused (Part 1 of 3)

Screening is a form of secondary prevention whereby a disease is diagnosed before it is clinically manifest or symptomatic, leading to early intervention and cure. By the time a man would show signs of prostate cancer, a cure would likely be unavailable. This fear has justified population-based prostate cancer since the introduction of a seemingly simple blood test: serum Prostate-Specific Antigen (PSA).

But since the introduction of this blood test, the results of screening, diagnosis, and treatment of prostate cancer has caused more harm than benefit. This is why in 2012, the US Preventive Service Task Force (USPSTF) gave prostate cancer screening a Recommendation D, opposing it altogether. As expected, prostate cancer screening by PSA and/or digital rectal exam (DRE) was abandoned by many primary care physicians (PCPs).

Fortunately, the USPSTF recommendation was revised to C in 2017, which recommends "selectively offering or providing screening to individual patients based on professional judgment and patient preferences. There is at least moderate certainly that the net benefit [of prostate cancer screening] is small". Hopefully, as newer screening tools are developed, shared decision-making can involve more specific details about the positive predictive value of these tests and how they may be more appropriately applied to each individual patient.

Urology is a unique setting. Most prostate cancers are slow-growing and inconsequential, rarely causing symptoms much less death. Our objective, therefore, is to diagnose and treat the high-grade tumors — the ones most likely to cause disease and death — and to avoid over-diagnosing and overtreating men with low-grade tumors. The dilemma has always been how to find the bad cancers early and how to spare men with less aggressive disease the stress and complications of unnecessary treatments.

But many PCPs and urologists lost sight of the objective. Performing a PSA test combined with a cholesterol panel and complete blood count (CBC) without the patient's knowledge was commonplace. Patients who did not meet the criteria for screening — having less than a 10-year life expectancy — were screened regularly anyway and sent to urologists if the PSA was above the threshold. Before 2012, 56% of men with less than a 9-year life expectancy were screened!

When I lecture, I post a slide stating: "PCPs do a poor job at screening". In the next slide, it says: "But urologists will biopsy them anyway". Two wrongs don't make a right!

Throughout my entire career, both before and after the USPSTF declaration, my approach to screening has remained the same. Obtaining informed consent to perform a simple blood draw was routine, even when it made my clinic visits significantly longer. Although I have performed over a thousand prostate biopsies, I would never approach these in a knee-jerk fashion. After 1999, my biopsy rate decreased by more than 18% due to my own improvements in shared decision-making and my mission to lessen fear and not capitalize on it. Consequently, I had the privilege of caring for so many men through Active Surveillance (AS), thus taking their confidence to another level.