Use of Prostate-Specific Antigen Testing Is in the Eye of the Beholder

The use of prostate-specific antigen (PSA) screening for prostate cancer is controversial. Various organizations have released conflicting messages regarding the use of the PSA screening test. In 2012, the US Preventive Services Task Force recommended against routine PSA screening, citing a lack of evidence regarding its benefits and known harms from prostate biopsy and overtreatment of indolent prostate cancer.¹

In this issue of JAMA Internal Medicine, Zavaski et al² report that since the release of the US Preventive Services Task Force statement, the rate of PSA testing has declined overall but still is performed more frequently for patients receiving PSA testing for preventive health reasons through their urologist rather than through their primary care physician. The vast majority of PSA testing is still performed by primary care physicians, but there seems to be a continued perception, more firmly held by urologists than by primary care physicians, that the screening is beneficial. Urologists may hold this belief because they have referred more men who request PSA testing or because they have seen more poor outcomes from metastatic prostate cancer. Regardless, recent data show some decline in the detection of early-stage prostate cancer, which likely reflects decreased ordering of PSA tests, and hopefully indicates avoidance of harms of cancer treatment, such as erectile dysfunction and urinary incontinence.³ We will need to await data on rates of metastatic disease and prostate cancer deaths to understand the full effect of less PSA testing. To our knowledge, such data were not available 30 years ago when the PSA blood test became available. The American Urologic Association Quality Registry was developed in 2014 to better track prostate cancer care and should produce the type of information our patients deserve.⁴

In the meantime, recommendations to reduce PSA screening will only strengthen with release of a Healthcare Effectiveness Data and Information Set measure⁵ targeting the elimination of PSA screening in men older than 70 years. It is essential that, along with improved collection of outcomes data, we also have outcomes data on the myriad novel diagnostic and risk stratification tools rapidly becoming available, such as magnetic resonance imaging or ultrasound fused-guided prostate biopsy and genomic testing. Without such evidence, we can be sure that differing entrenched beliefs between urologists and primary care physicians will only become more expensive. Meanwhile, the widespread use of the PSA test should serve as a cautionary tale of the importance of first establishing that benefit exceeds harms before recommending new cancer screening tests.

Conflict of Interest Disclosures: None reported.