By Roy Benaroch, M.D., Emory University Affiliated Hospitals
Prostate-Specific Antigen (PSA) testing had always been a topic of debate among the members of the medical community. Over the years, the outlook toward PSA screening has changed mainly because of the way it has been portrayed by the media. In 2012, the US Preventive Services Task Force (USPSTF) released an official recommendation for PSA screening that led to the drafting of new guidelines that clearly recommended against PSA-based cancer screening for prostate cancer.
Media’s Portrayal of the Changing Perspectives and Recommendations About PSA Screening
According to a report by ABC News, the government advisory panel tasked with issuing cancer screening guidelines made a final recommendation on PSA tests—not needed, regardless of age. In the news story, headlined “USPSTF Scuttles Recommendations for PSA Screening Test”, ABC quotes one of the physicians of the US Preventive Services Task Force who stated that “of 1,000 men who are screened, at most one will avoid a prostate cancer death”. The physician conveniently rounded off the data available at that time. ABC’s story also provides a secondary point of view by quoting two urologists who supported PSA screening. According to one of the urologists, the majority of the doctors who deal with prostate cancer patients believe that the USPSTF underestimated the benefits and overestimated the harms of PSA screening. Over the next few years, the controversy continued to simmer and though most of the physicians agreed that PSA screening had significant drawbacks, many continued to use the PSA test.
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Release of a Proposed Revision to USPSTF’s Guidelines
In 2017, NPR ran a headline, “Federal Task Force Softens Opposition To Routine Prostate Cancer Screening”, that spoke of a proposed revision to the USPSTF’s guidelines, breaking down their recommendation by age. Men aged between 55 to 69 are encouraged to decide individually with their doctors by weighing the pros and cons, while men older than the given range are not recommended for PSA screening. According to the chair of the new task force, the change in their decision was based on new research. It specifically relied on a European study according to which PSA screened men had a 20% reduced chance of dying of prostate cancer.
It was also believed that most of the doctors in the US, when counseling men with an abnormal PSA test, recommended watchful waiting rather than immediate therapy, which lessened the risk of unnecessary treatment. According to USPSTF, the net benefit of the revision was that screening 1,000 men would now save “one or two lives”. The official recommendations from the US government guidelines and guidelines from the US medical societies are to talk freely and frankly about the potential benefits and risks of PSA screening with patients, thereby allowing them to decide individually.
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USPSTF’s Summary Graphic Titled: “Is Prostate Cancer Screening Right for You”
To help physicians and patients understand the statistics related to PSA screening, USPSTF developed a summary graphic titled “Is Prostate Cancer Screening Right for You”. According to this, every 240 out of 1,000 men, aged 55 to 69, screened with a PSA test, get a positive result that may indicate cancer. Of those 240, 100 men will have a biopsy that confirms cancer. Of those 100, 80 will undergo surgery or radiation treatment, of which 60 will experience serious complications like impotence or incontinence and three will avoid having the cancer spread to other organs. And one or two will avoid death from prostate cancer.
Difficulty to Convey Nuance
There is a nuance in the newest recommendation that stresses shared decision-making between patients and doctors based on critical discussion of the statistics presented by the USPSTF. It is fair to say that nuance can be difficult to convey, especially in brief videos such as the “Prostate Prep Talk”. This is a 15-second video that was promoted during the September 2017 “Prostate Cancer Awareness Week”. The video and the website do not convey anything close to the nuances of the recommendations. Instead, they encourage men to schedule a ‘free’ PSA screening directly at a laboratory, where the pros and cons of PSA testing are not discussed with the men. CBS, Fox, and numerous newspapers widely publicized the prostate pep talk campaign. The message that these media outlets relayed was that prostate cancer is common and that screening was an important way for men to stay healthy. The video and awareness campaign for PSA screening was funded by a partnership of the NFL Alumni Association, Labcorp, and the Cancer Treatment Centers of America.
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How Health Media Stories Sometimes Relish Controversy
In 2017, a few months after the USPSTF changed the recommended guidelines for PSA screening, the LA Times reported on the latest new study of screening, headlined: “PSA Screening for Prostate Cancer Saves Lives After All, Study Says.” According to the LA Times, the US guidelines dumped the decision squarely into the laps of patients and their doctors. This is true as all medical decisions ought to take place between patients and their doctors. The LA Times further stated that the new research calls this decision into question because it showed a reduction in deaths of 25–32% with PSA screening. Toward the end of the story are warnings about misleading results. However, these warnings are overshadowed by the overall tone of the article, that the USPSTF is wrong, which is proved by the new research. The LA Times failed to mention an important caveat about the new study. It was not a new clinical study of new patients, but rather new mathematical manipulations of data from prior clinical studies that had found different impacts of PSA screening. According to the authors, the results could have been affected because some men who had been randomized into the non-screening groups had chosen to get screened anyway. The research also tried to control healthy user bias. This means that men who choose to get screened may be healthier overall than men who choose not to be screened.
In conclusion, it can be said that a mathematical study cannot be considered as compelling as a real-life, real-patient study. There are many assumptions and some complicated math that can easily sway these kinds of modeling papers. If the numbers are expressed in terms of the absolute change in risk, they really do not look very impressive. One must always pay attention to these kinds of results and remember that the thing to look for is an absolute change in risk, not a relative change that can exaggerate an insignificant number.
Common Questions About the Media’s Role in PSA Screening
The government advisory panel tasked with issuing cancer screening guidelines made a final recommendation on PSA tests—not needed, regardless of age.
According to the proposed revision of the USPSTF’s guidelines, men aged between 55 to 69 are encouraged to decide individually with their doctors by weighing the pros and cons, while men older than the given range are not recommended for PSA screening.
To help physicians and patients understand the statistics related to PSA screening, USPSTF developed a summary graphic titled “Is Prostate Cancer Screening Right for You”.
Nuance can be difficult to convey, especially in brief videos such as the “Prostate Prep Talk”. The video and the website don’t convey anything close to the nuances of the recommendations by the US government.
In its story PSA Screening for Prostate Cancer Saves Lives After All, Study Says, the LA Times failed to mention that it was not a new clinical study of new patients, but rather new mathematical manipulations of data from prior clinical studies that had found different impacts of PSA screening.
