Their Unwitting Sacrifice

Last week, at their conference in San Diego, the American Urological Association (AUA) released its “Early Detection of Prostate Cancer: AUA Guideline.”[1]  The document began by introducing its purpose and audience: “This guideline addresses prostate cancer early detection for the purpose of reducing prostate cancer mortality with the intended user as the urologist.” In other words, the AUA Guideline advises urologists on the controversial use of the PSA blood test to screen “average” men for further diagnostic tests to see if prostate cancer is present.  (The PSA test itself says nothing about the presence of absence of cancer.)

The AUA did not issue a wholesale rejection of PSA-based screening, as the U.S. Preventive Services Task Force (USPSTF) did in 2012.  The AUA’s press announcement underscores this, stating, “it should be noted that the AUA remains in disagreement with the U.S. Preventive Services Task Force in recommendation against prostate cancer screening in all men, regardless of age or risk, without even considering a discussion of the risks and benefits of screening.”[2]

1 in 1000

1 in 1000

Although it does not reject the PSA screening test outright, the AUA takes a step back from its former recommendation of mass screening regardless of age.  As NPR (and others in the  media) reported, “if they’re heeded, [the guidelines] would dramatically reduce the ranks of men who would be candidates for PSA testing.”[3]   The vans that had previously showed up at public health fairs to offer free PSA screening are now likely to disappear.

So, who exactly populates these “reduced ranks?”  The guidelines define four age-based cohorts, each with its own recommendation:

  1. “The Panel recommends against PSA screening in men under age 40 years.”
  2. “The Panel does not recommend routine screening in men between ages 40 to 54 years at average risk.” (Exceptions include African-American men and those with a family history of the disease.)
  3. “The Panel strongly recommends shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man’s values and preferences.”
  4. “The Panel does not recommend routine PSA screening in men over age 70 years or any man with less than a 10 to 15 year life expectancy.”

If widely adopted, what are the guidelines’ long-term implications for men younger than 55?  The AUA acknowledges the obvious tradeoff: “The decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment.”  Thus, the AUA recommends no screening for men under 40 and very limited screening for men 40 to 54 years old.

Not surprisingly, the guidelines emphasize the good news: many unneeded biopsies–and consequently, unnecessary treatments–will be avoided, reducing the number of men suffering the all too ugly side effects of treatment.  In addition, there will be substantial economic savings to society as a whole.

The bad news, however, is that younger men–at least younger men who are neither African American nor have a family history–will generally not be screened prior their 55th birthdays.  Some will therefore arrive at their urologist for their first PSA test at age 55 with an advanced (and therefore incurable) disease.  This “new” situation will be exactly the same as it was before the invention of the PSA test in the mid-1980s.

Admittedly, the number of these men will be small. The AUA asserts just one in one thousand.

These men will be the statistical cost of eliminating widespread PSA screening at earlier ages.  Like every public health decision, every benefit—fewer men needlessly over-treated and suffering the consequences of that treatment—has a tangible cost.  In this case, some men will suffer an early death from aggressive cancer because they were not screened early enough for the disease to be effectively treated.

In societal terms, the AUA guidelines—which now align with guidelines form the American Cancer Society—are a rational choice.  Life is full of ugly tradeoffs.

Men diagnosed with aggressive prostate cancer before the age of 55 do exist. I know many of them. Not surprisingly, almost all of them are convinced that their lives were saved due to a PSA test that was conducted at an age that now falls outside the AUA’s guidelines.

These men are alive and well, cured of a cancer caught early.  The grim fact is that prostate cancer is almost always symptom-free until it has advanced beyond the confines of the prostate gland.  Now, men who would have joined the ranks of these younger survivors will now likely not be diagnosed until they present with advanced–and therefore incurable–disease.  These men will suffer and often die, so that a larger number of men will be able to forgo unnecessary treatment and its unpleasant aftermath.

If cancer has taught me anything, it is that life is unfair.  But is it too much to ask the USPSTF, the AUA, and the American Cancer Society–which somewhat ironically claims to be the “official sponsor of birthdays”–to acknowledge the existence of these very real men—and the unwitting sacrifice they will be making?  Or will these men be forever consigned to the anonymity of statistics?

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