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    PSA screening decline is troubling trend

    Henry Rosevear, MDHenry M. Rosevear, MD

    Dr. Rosevear, a member of the Urology Times Clinical Practice Board, is in private practice in Colorado Springs, CO.


    I have been practicing urology for just under 2 years now and in that period have diagnosed six patients with metastatic prostate cancer at initial presentation. Anecdotally, this is not an uncommon trend. A number of urologists I spoke with at the AUA annual meeting in New Orleans recently reported seeing more prostate cancer patients with late-stage disease at presentation.    

    All six of my patients were some version of the same story. None of them had either a rectal exam or PSA in years. All had been told that both were useless, and most could even describe the U.S. Preventive Services Task Force (USPSTF) recommendations on PSA screening. All were shocked with the final diagnosis. One is seeking legal advice.

    Read - USPSTF guide’s impact: The jury is still out

    We now have credible evidence that the use of the PSA as a screening test by primary care physicians has declined since the USPSTF issued its "D" grade. At the AUA annual meeting, Dr. Werntz et al showed a 50% decrease in the use of PSA testing by a group of primary care doctors since the USPSTF recommendations were published in 2012. This portends poorly for patients with prostate cancer.

    This trend is incredibly important to discuss for a few reasons. First, it is confirmation that we are entering a new era (returning to a previous one?) when prostate cancer patients will walk into your office not with an elevated PSA but rather with symptoms. Just look at the SEER data prior to widespread PSA testing. The number of patients presenting with prostate cancer was not dramatically lower; they simply presented with significantly later stage disease.

    NEXT: "We need a new CPT code for prostate cancer screening counseling."

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    Henry Rosevear, MD
    Dr. Rosevear, a member of the Urology Times Clinical Practice Board, is in private practice at Pikes Peak Urology, Colorado Springs, CO.

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      Dr. Rosevear, I found your editorial in July 2015 both amusing and somewhat unsettling, enough so that I write my first response to an editorial in 35+ years which is as long as I have been practicing general urology. The USPSTF response to PSA was originally ridiculous ( but nothing that would surprise me from a government committee) and something I can not, have not, and will not support. You are right to think that we will go back to the dark ages without using PSA's and even realizing it has limitations, used judiciously it gets the job done. When I started out in practice we used rectal exams and prostatic acid phosphatase. You might as well flip a coin to decide whether to do a biopsy !There were far more men with advanced prostate cancer requiring stilphosterol IV to reduce their severe pain of boney metastatic disease. The PSA was a godsend and as the statistics would show the incidence of new prostate cancer cases increased about 300% in the first 5 years after we begin using the PSA as a screening modality. Anecdotally I don't see the massive boney metastatic disease patient that seemed so frequent in my early years. And anecdotally survival rates seem to be better too as would be anticipated. If a good substitute for PSA is presented I will change but I currently don't see it. Fortunately, locally, the primary doctors still do screening with PSA's and we continue to diagnose prostate cancer early. I may be a little more reticent about biopsiing slightly elevated numbers but they are followed and biopsied for changes that are worrisome. The "old days" haven't returned yet but will if we continue this headlong deteriorating ramble. I wouldn't look forward to it but expect that the fantastic new hope and changes will have pushed me out of practice by then. Sincerely, Michael Lake, MD Urologist, Columbus, GA


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