PSA screening: And now…a message from our experts

A 62-year-old man presents to the emergency room with severe back pain.A workup reveals a rock-hard prostate, PSA of 75 and widespread prostate cancer bone metastases to his pelvic bones, rib cage, and spine.Most of the readers of this issue of the CUAJ will be keenly aware of the recent release of the Canadian Task Force on Preventive Health Care (CTFPHC) guidelines recommending against routine PSA screening for prostate cancer. 1 Furthermore, many of you will be experts in the management of patients with prostate cancer, well-versed in the ambivalent literature surrounding population-based PSA screening and cognizant of the intricacies associated with the need for disconnecting diagnosis and treatment of early disease.You may be greatly concerned that the CTFPHC recommendations, aimed at a primary care audience and policy makers, have bolstered those of others including the US Preventive Services Task Force and Choosing Wisely.Will these recommendations cautioning against PSA screening result in a set-back in the prostate cancer conversation?Will we start to see the above patient present more commonly in our practices?The CTFPHC states that the evidence supports an increased risk of harm with routine testing, with uncertain benefits.Their key recommendations include:• For men under age 55 and over age 70, the Task Force recommends not using the PSA test to screen for prostate cancer.• For men 55 to 69, the Task Force also recommends not screening, although it recognizes that some men may place high value on the small potential reduction in the risk of death and suggests that physicians should discuss the benefits and harms with these patients.The overarching goals and objectives of the CTFPHC to put forward evidence-based recommendations about clinical maneuvers aimed at primary and secondary prevention is important in our current healthcare landscape.The make-up of the CTFPHC includes volunteer clinicians and methodologists, and specifically excludes content experts in the field, presumably to obviate any perceived conflicts of interest.However, the methodology for the process, well-described on the Task Force website, 2 does allow for more widespread consultation with such experts in prostate cancer biology and management.Such input into the current recommendations appears to be lacking in the document and, in our opinion, contaminates the effort with a few unfortunate mistakes and substantively misleading statements.So what do the experts say?The CUA has released a number of excellent commentaries outlining some factual errors and concerns with interpretation of the CTFPHC document.3,4 Perhaps most concerning is the observation that although the Task Force confirms that PSA screening likely results in a reduction in cause-specific mortality, it highlights that there is "conflicting evidence suggesting a small and uncertain potential reduction in prostate cancer mortality."The messaging confuses the reader and distracts from best evidence to date suggesting that screening reduces prostate cancer deaths by 21% to 44%.We encourage you to read the full response from the CUA, which includes further relevant information the Task Force has yet to adequately address.Similarly, a number of key stakeholders and opinion leaders, experts in contemporary prostate cancer diagnosis and management, have spoken up and offered thoughtful and rational advice for primary care physicians and prostate cancer specialists alike.3,5 We summarize some of these thoughts below:1. Men should have a discussion about the risks and benefits of PSA testing especially those between the ages of 55-69 and those at higher risk of aggressive disease.2. Prostate cancer diagnosis must be uncoupled from prostate cancer treatment.3. Avoid PSA testing in men with less than 15-year life expectancy, unless these men have a previously elevated value.

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