Screening for Prostate Cancer Despite Scaled Back USPSTF Guidelines

While the US Preventive Services Task Force (USPSTF) has issued recommendations against routine PSA-based screening for prostate cancer, E. David Crawford, MD, feels as though this is a step in the wrong direction.

E. David Crawford, MD

While the US Preventive Services Task Force (USPSTF) has issued recommendations against routine PSA-based screening for prostate cancer, E. David Crawford, MD, feels as though this is a step in the wrong direction.

“One of the biggest challenges right now in prostate cancer is early detection,” says Crawford, a professor of Surgery, Urology, and Radiation Oncology and an endowed chair in Urologic Oncology, University of Colorado, in an exclusive interview with Targeted Oncology. “Because the USPSTF and other organizations kind of put a damper on the standard early detection methods, we need another solution.”

The recommendation against the use of prostate specific antigen (PSA) testing was published in May 2012. At the time, the USPSTF task force gave the screening test a grade of D, translating to the idea that there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

Crawford says that while the decision was made several years ago, he feels as though prostate cancers are still being detected at later stages, rather than being caught at an earlier stage through screening.

Crawford cites his involvement in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial as an example as to why PSA screening is important. He adds that in 2012, he and his team of researchers began working with the Henry Ford Health System database to look at the correlation between PSA scores and prostate cancer risk. The determination from that database study was that a PSA of 1.5 was a safe zone, while a PSA score of between 1.5 and 4 was a danger zone.

"Knowing that a PSA of 1 had been previously identified as a cutoff, we looked at people who had a PSA of less than 4 to see what happened to them over 5 years," he said.

"In an analysis of 22,000 men with an initial PSA between 1 and 4 in the cohort at Henry Ford, we found that those patients with a PSA of less than 1.5 had a 0.4% risk of being diagnosed with prostate cancer within 5 years. That is very low. For patients who had a PSA of 1.5 to 4, the risk of developing prostate cancer within 5 years was 8% to 12%, with the 12% representing African-American risk and the 8% representing Caucasian risk."

Looking at the current treatment paradigm in prostate cancer, Crawford says urologists are only ordering 6% of the overall testing being done on patients. In comparison, internal medicine doctors are ordering roughly 64% of tests, while family medicine doctors order another 23%.

"To address this issue, urologists need to work with family doctors. There was an initiative to get them to educate patients about screening choices and risks so they could make an informed decision. We felt that there should be an informed decision-making process with patients before a PSA is ordered because the test can set off a series of events, including unnecessary biopsies, overdiagnosis, and overtreatment. We gave them a lot of information to do this," he said.

Crawford urges family medical practices to inform patients with a PSA score of below 1.5 to have themselves checked within the next 5 years, while they should consider patients over that PSA score as a higher risk. He adds that approximately 70% of men have a PSA of less than 1.5, leaving the remaining 30% as ones that may require some attention.

For men whose PSA score is over 1.5, medical professionals should take the appropriate, but not extreme, courses of action.

"For those men, doctors should not necessarily order a biopsy, but they should go to the next step. There are new tests out, such as the 4KScore test and the PCA3 test. The PSA can also simply be repeated, and then doctors should take action behind that. Patients should only be biopsied if they have a PSA of more than 1.5. They undergo the next level of testing, and then it is determined if they are at high risk," he said.