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Podcast Recap | PSA screening: What you need to know

September 28, 2023

In this episode of The Podcast by KevinMD, host Kevin Pho, MD, interviews urologist Dr. Stephen Lieberman about his perspective on the evolution of PSA screening and his insights on how patients can navigate and benefit from the latest changes in prostate care.

Podcast length - 25:55 min.

5 Key Takeaways

1. Despite being introduced nearly four decades ago, controversy still persists over whether or not to perform PSA screening for prostate cancer.

In 2012, the USPSTF recommended against screening all men with the PSA test, concluding that the benefits of the test did not outweigh the risks. Then in 2018, the USPSTF issued a revision to include shared decision-making for the PSA test for men ages 55 to 69, reflecting emerging evidence of longer-term benefits and widespread adoption of active surveillance after detection of low-risk disease.

Currently, the “non-screeners” are physicians who take their cues from the USPTF’s original 2012 recommendation. According to Dr. Lieberman, their position is “we don’t need to screen for prostate cancer by doing PSAs on our patients because most prostate cancers are indolent and slow-growing, and men aren’t going to die from prostate cancer. The treatment (surgery, radiation, hormones) is worse than the disease.”

The pro "screeners" are urologists, oncologists, and radiation oncologists, who believe that early detection of prostate cancer using PSA as an initial marker is not only possible, but also saves lives. More importantly, early detection prevents morbidity from advanced and/or metastatic disease.

Nonetheless, the PSA test has proven to be effective as an early detection tool. Half of the prostate cancer patients in the early 1980s had advanced or metastatic disease. But after the widespread use of PSA screening, 40 years later, the percentage of patients presenting with advanced and metastatic disease fell from 50% to less than 10%.

2. Although current USPSTF guidelines for men ages 55 to 69 years recommend shared-decision making about the risks and benefits of doing a PSA test, in actual clinical practice, PCPs may not have the time or may lack the proper information to have this discussion with their patients.

Preferring to call it early detection vs. screening, Dr. Lieberman says that if a patient wants to know whether or not they are at clinical risk of having prostate cancer, then the first thing to do is a prostate test.

"I don’t think there are any risks/benefits of having an $8 blood test. If the person has the $8 blood test, I would recommend a risk assessment and there are plenty of risk assessment calculators available online," says Dr. Lieberman.

In general, he expresses concern that the USPSTF recommendations against PSA screening are based on flawed or misinterpreted data and apply to all patients regardless of risk. When the USPSTF issued a Level D recommendation against PSA-based screening (2008 and 2012), that recommendation was based on three studies (PLOC, ERSPC, and Gothenburg).

"Not one urologist or oncologist was on the USPSTF committee and the recommendation faced extensive criticism in the literature. Morbidity from metastatic disease and treatment was not part of their analysis," he explains.

After the original Level D recommendation by the USPSTF, there was an increase in advanced/metastatic disease, which Dr. Lieberman points out actually prompted a revision of USPSTF's recommendation to Level C in 2018.

USPSTF currently recommends against doing a PSA test or rectal exam on anyone over 70. Dr. Lieberman disagrees with this recommendation.

3. What he'd most like to communicate to PCPs is that there’s no such thing as an abnormal or normal PSA: Everybody has an individual risk of having clinically significant or clinically insignificant prostate cancer.

"PSA is like a fingerprint," says Dr. Lieberman. Risk information can easily be obtained via an online risk calculator that with percent-free PSA can tell the patient what the risk will be: If percent-free PSA is less than 10%, there’s a marked increased risk of having clinically significant prostate cancer; if the percent-free PSA is over 22%, there’s a marked decreased risk of having clinically significant prostate cancer.

4. The risk of early detection strategies has been significantly reduced by the introduction of multi-parametric MRI and the risk of biopsies by using a transperineal approach.

Dr. Liebermann acknowledges that USPSTF was right in saying urologists were performaing too many prostatectomies that caused excessive morbidity from either the surgery or from radiation.

However, he argues that the current strategies that urologists are now using do not increase the detection of clinically insignificant or indolent disease. Nor do they increase the number of unnecessary biopsies that are done. In fact, the reverse is true: There's actually a decrease in the number of biopsies.

Moreover, clinicians now have a slew of tools in their aresenal to reduce a patient's risk of procedures such as biopsy, surgery or radiation being done unnecessarily:

• Multi-parametric MRI is the main test.
• PSA itself has proven to be an excellent test to assess response to treatment. An undetectable PSA after treatment is indicative of an excellent response to treatment (surgery, radiation, hormone ablation for the treatment of metastatic disease). A rising PSA after treatment is indicative of recurrence.
• Risk assessment can be further enhanced by tests such as PSA velocity (change in PSA over time), PSA density (PSA/prostate volume), % free PSA, PCA3 (prostate cancer antigen urine test), isoPSA, and recently newer tests like ExoDx (urine biomarker).
• Genetic markers can also be used in patients with FHx of prostate cancer.

5. Early detection of clinically significant prostate cancer definitely reduces the incidence and prevalence of advanced and metastatic disease.

The cure rate for removal of locally confined prostate cancer—clinically significant or not—is 95%. Thus, mortality from prostate cancer for patients screened or detected early is "practically eliminated," according to Dr. Lieberman.

Of course, early detection is preferable to metastatic disease. Patients with metastatic disease face increased risks from that metastatic disease, including being on leuprolide for the rest of their lives, undergoing radiation for pathologic bone metastases, or experiencing fractures.

"So, if you are 40 and asking whether or not to have PSA, yes, you should," cautions Dr. Lieberman, "However, patients who are 75 and have other clinical comorbidities, may not need to have a PSA ..."

Any views, thoughts, and opinions expressed in this podcast recap are solely that of the host and guests and do not reflect the views, opinions, policies, or position of epocrates and athenahealth.

Sources:

(2023, September 24). The Podcast by KevinMD. PSA screening: What you need to know. https://www.kevinmdpodcast.com/psa-screening-what-you-need-to-know/

Lieberman, S. (2023, August 29). KevinMD.com Is a PSA test right for me? A urologist answers. https://www.kevinmd.com/2023/08/is-a-psa-test-right-for-me-a-urologist-answers.html

USPSTF. (2018, May 8). Final Recommendation Statement: Prostate Cancer Screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening