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Us TOO FLORENCE - BEHIND THE HEADLINES BY BOB HORNEY - PROSTATE CANCER SURVIVOR - Us TOO CHAPTER LEADER Published July 13, 2016, The Siuslaw News Oh, how the pendulum doth swing! Of course, I'm referring to the use of the PSA test for prostate cancer screening. It has swung from screening men every year beginning at age 50 to no screening at all for any man. Prior to the late 1980s, prostate cancer screening was accomplished by the finger, known as the Digital Rectal Exam (DRE). The problem with the DRE was that by the time an abnormal prostate gland was felt by a physician, the cancer was often long gone. When that was our only method of screening, 21 percent of newly diagnosed men already had metastatic prostate cancer. One can imagine the hopes of men and their families when the PSA test came along in the late 1980s and was able to signal prostate problems, including prostate cancer, years before the DRE would show any abnormality. All of a sudden there seemed to be a better way of finding early prostate cancer. This was about the time I turned 50 and there was not much discussion about being tested - it was just done...fortunately. In 2007, Hans Lilja and colleagues presented results of the Malmo Preventive Medicine Study in Malmo, Sweden, showing a single PSA test at 44-50 years of age could predict a future risk of developing prostate cancer. The investigators went on to show that 80% of advanced cancers (T3, T4 or metastatic at diagnosis) occurred in men with PSA levels above the median at those ages. In 2009, the American Urological Association (AUA) issued new clinical guidelines regarding early detection of prostate cancer and the PSA test. The AUA decided waiting until age 50 was missing too many men and recommended the PSA test should be offered at age 40 along with a comprehensive risk assessment. The AUA said future risk of prostate cancer was closely related to a man's PSA score and a baseline PSA level above the median for age 40 was a strong predictor of future prostate cancer. So, there we were, rolling along with prostate cancer mortality dropping 40 percent and the National Cancer Institute reporting 40-70 percent of that drop being directly attributed to PSA screening. Then came the USPSTF's controversial recommendation that no man should receive PSA screening - period! This was at a time when 91 percent of newly diagnosed men had localized disease only 4 percent of newly diagnosed men were metastatic! The USPSTF said that over-diagnosis and over-treatment resulted in more harm, such as incontinence and impotence, than benefit of lives saved. The USPSTF disregarded the above Malmo Study. Unfortunately, when the USPSTF came out with its 2012 recommendation of no PSA screening, the AUA dumped its baseline recommendation and instead recommended men between ages 55 and 69 discuss PSA testing with their doctors. The AUA said this revised recommendation was "evidence-based" whereas its earlier recommendation was "consensus-opinion." With this change, the AUA effectively turned its back on young men between the ages of 40 and 55. The Large Urology Group Practice Association (LUGPA), of which Oregon Urology Institute (OUI) is a member, broke with the AUA at that point, remaining committed to the baseline PSA test while adjusting the recommended age from 40 to "during one's 40s." They had experienced the life-saving effects of baseline testing, confirming the Malmo Study findings. Jump now to June 2016, to a prospective evidence-based study of U.S. men that finds mid-life PSA levels can accurately predict who will be more likely to develop prostate cancer and, even more significantly, point to those who are at high risk of developing lethal prostate cancer in the next 30 years. This prospective study validates the Malmo Study and the recommendations of LUGPA and OUI. Our urologists provide optimum prostate cancer detection by recommending a baseline PSA test (along with a risk assessment) while in our 40s, comparing the baseline test results with the median PSA for our age and using all of that information as a risk-stratified guide for our future PSA tests. Yes, AUA, it is now evidenced-based! |
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