15 Nov Prostate Biopsies and Prostatectomies Drop After PSA Recommendation Changes
MedicalResearch.com Interview with:
Jim C. Hu, M.D., M.P.H.
Ronald P. Lynch Professor of Urologic Oncology
Director of the LeFrak Center for Robotic Surgery
Weill Cornell Medicine
New York Presbyterian/Weill Cornell
New York, NY 10065
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: The US Preventative Services Task Force (USPSTF) recommended against PSA testing in men older than 75 years in 2008 and more recently in all US men regardless of age in 2012. This was largely based on a faulty study, the prostate, lung, colo-rectal and ovarian screening study. We demonstrated in May 2016 that this randomized trial did not compare screening to no screening or apples to oranges, as it set out to do. It compared screening to screening. Although controversial, the guidelines were well-intentioned, as recognize that there is over-diagnosis and over-treatment of men with prostate cancer. Given this background, the goal of our study was to explore the downstream consequences of the recommendation against PSA screening. As such, we explored 3 separate databases to characterize national procedure volumes for prostate needle biopsy and radical prostatectomy, or surgery to cure prostate cancer.
The main finding was that prostate biopsy numbers decreased by 29% and radical prostatectomy surgeries decreased by 16% when comparing before to after USPSTF recommendations against PSA screening. Therefore practice patterns followed policy. Prostate biopsies are usually performed due to an elevated, abnormal screening PSA. However, it is also performed to monitor low-risk, slow growing prostate cancers. We also found that while the overall number of prostate biopsies decreased, there was a 29% increase in the proportion or percentage of biopsies performed due to active surveillance, or monitoring of low risk prostate cancers which should be done periodically. Therefore we provide the first national study to demonstrate that there is less over-diagnosis and over-treatment of prostate cancer.
However, the concern is that we also recently demonstrated that there is more aggressive prostate cancer on surgical pathology for men who go on to radical prostatectomy. They have high grade, higher stage cancers, which have a lower chance of cure. The link is:
MedicalResearch.com: What should readers take away from your report?
Response: Readers should take away that professional guidelines against PSA testing had a significant effect on the reduction of prostate biopsies and radical prostatectomies. However, I believe that this controversial topic is not so clear cut. There may be some men who may miss the window of curability due to a wholesale adoption of no PSA screening. A thorough, individual discussion of the risks and benefits of PSA testing should occur with medical professionals.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Response: There have been recent studies that demonstrate that there is more aggressive prostate cancer at treatment and diagnosis. This presentation contrasts with our findings of decreased prostate biopsy and surgery and the timeframe for both occur coincidentally around the time of the recommendation against PSA screening and a drop off in prostate cancer screening. This is not a black or white issue and future research should seek to clarify the value of baseline PSA testing, or the practice of a man obtaining a PSA in his 40’s to early 50’s. This number can them guide him on his lifetime risk of developing prostate cancer and the frequency and need for future testing, if any.
MedicalResearch.com: Is there anything else you would like to add?
Response: This is a very controversial issue. I’ve attached a slide that demonstrates that the adoption of PSA testing was accompanied by a significant drop in metastatic prostate cancer; however, the adoption of mammograms did not change the likelihood of metastases at diagnosis. More recently, Ben Stiller was criticized by some for coming out and saying that PSA testing saved his life. He was diagnosed with a Gleason 7 prostate cancer in his late 40’s, that likely would have been problematic over time. I do not think women would be criticized for an individual choice of choosing mammography.
MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.
Halpern JA, Shoag JE, Artis AS, Ballman KV, Sedrakyan A, Hershman DL, Wright JD, Shih YCT, Hu JC. National Trends in Prostate Biopsy and Radical Prostatectomy Volumes Following the United States Preventative Services Task Force Guidelines Against Prostate-Specific Antigen Screening. JAMA Surg. Published online November 02, 2016. doi:10.1001/jamasurg.2016.3987
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