It’s a fine line between overdiagnosing and overtreating prostate cancer. A recent study showing an increase in the rate of advanced disease in men over 50 doesn’t serve to clarify the process, according to Dr. Joseph Wagner, chief of urology at Hartford Hospital.
A study in the Journal of the National Cancer Institute indicated that a U.S. Preventative Services Task Force (USPSTF) recommendation five years ago downplaying the need for annual prostate specific antigen (PSA) screening in all men triggered the increase. At the same time, the incidence of early disease decreased, leading study authors to assert that the screening decline caused more cases to advance before being discovered.
“When the PSA was first used to screen for prostate cancer in the 1990s, there was a huge increase in the number of cases being diagnosed, and the number of deaths started to decline because we were finding cancer and treating it early,” Dr. Wagner said. “At the same time, we were diagnosing a bunch of cases that never needed to be treated.
“You have to walk the line between overdiagnosing and overtreating and underdiagnosing and undertreating.”
With the PSA recommendation five years ago, he said a second “backsnap” has created an increase in the diagnosis of advanced-stage disease.
Understanding the implications requires knowledge of the data around prostate cancer, which is the second-most common cancer and second leading cause of cancer death in American men. The PSA, a blood test, along with a digital rectal exam, is the only screening test available to detect the disease.
Dr. Wagner made two observations. Cases are not being diagnosed until they are more advanced, which is bad. But, secondly, he said the USPSTF recommendation also means men are not undergoing potentially life-altering treatment for non-aggressive forms of prostate cancer. About 75 percent of men, he noted, have had a biopsy of their prostate when they don’t need one simply because they had a positive PSA.
“This is actually good,” he said of his second point. “Treatment can leave a man impotent or incontinent. The rates of this are pretty high. We have to treat 12 to 20 localized cancers to save one life. Meanwhile, we’re causing all these other side effects.”
What is needed, he continued, are better tools to determine which men need to have regular PSA screening and which do not. That way, providers can have a conversation with their patients and decide together how to proceed based on the patients’ individual needs.
A DNA test could be more sensitive than the PSA, helping providers better identify if a man has a form of prostate cancer that needs to be treated, Dr. Wagner said.
“Every guy with more than a 10-year life expectancy should get a periodic PSA screening,” he said. “It is important to remember an elevated PSA does not mean a man has cancer. It also doesn’t mean they’ll have a type of prostate cancer that needs to be treated.”
For more information on PSA testing and prostate health at the Hartford HealthCare Tallwood Urology & Kidney Institute, click here.
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