09 Feb PSA Screening: Primary Care Doctors and Urologists Have Different Views
MedicalResearch.com Interview with:
Dr. Quoc-Dien Trinh MD
Assistant Professor, Harvard Medical School
Brigham and Williams Hospital
Medical Research: Please briefly explain the potential benefits and harms of PSA testing, the rationale for screening all men, and the reason U.S. guidelines now recommend against routine screening.
Response: The goal of cancer screening is to detect the disease early, and consequently treat it before it becomes more aggressive and spread to other parts of the body (which ultimately leads to death). However, cancer screening may lead to overdiagnosis (detecting cancers that would not have been a problem for a while) and overtreatment. The latter is a problem for prostate cancer, because surgery and radiation therapy (the currently accepted first-line treatments for localized prostate cancer) have significant long-term adverse effects on sexual and urinary function.
I wouldn’t say that ‘US’ guidelines are against screening. Many professional societies continue to recommend some form of joint decision-making with regard to PSA screening. the USPSTF recommends against screening for all – they argue that the harms mentioned above outweigh the benefits.
Medical Research: Why do you think primary care physicians cut back on PSA screening much more than urologists after the U.S. guidelines against universal screening came out? Is it possible men who see urologists might have more risks for prostate cancer, or symptoms that need exploration? Or is it possible that specialists are more likely to screen more aggressively? Or what do you think might explain the difference?
Response: I think it’s a combination of factors. First, the USPSTF recommendations may resonate more to primary care physicians than the AUA or NCCN (to name a few) recommendations, which are directed at urologists and oncologists, respectively.
Second, several health care organizations have (or will start to) adopted quality metrics for PCPs based on the compliance to accepted recommendations (such as not getting PSA tests per USPSTF, whether you agree with that or not).
Third, PCPs have so many things to address in a visit, the knowledge that this is no longer a recommended test according to USPSTF has certainly impacted their decision to stop checking the PSA.
Regarding the second part of your questions: we excluded patients who had a history of prostate cancer, elevated PSA, BPH, prostatitis – all reasons for repeat PSA testing. Also, we only included visits marked as ‘preventive care’. Regardless, our findings suggest that PCPs and urologists have quite different views on PSA testing.
Medical Research: Based on the findings, would you say it’s better for men considering screening to see a primary care physician or a urologist, and why? Who should men trust most in this situation and why?
Response: I think it’s not really the specialty of the provider that makes a difference but rather the provider’s knowledge base and willingness to discuss the pros and cons with the patient that matters. I don’t think it’s acceptable to get annual PSA tests on every man that walks through the door, but neither is disregarding patient’s questions about PSA testing.
Medical Research: How can men know if PSA screening is right for them – are there certain questions they should ask to help them make the most informed decision? And are there certain patients who generally will need screening, or some patients who generally won’t benefit from a PSA test?
Response: There is much evidence that men with limited life expectancy do not benefit from PSA testing, and I think all experts can agree on that. The rest is a matter of opinions and expert panels – I do feel strongly that some men are more at risk of prostate cancer (family history, certain racial groups), and I’m concerned about what will happen to these men given the current USPSTF recommendations and trends in PSA testing.
Dr. Quoc-Dien Trinh MD (2016). PSA Screening: Primary Care Doctors and Urologists Have Different Views