The PSA controversy continues to plague men’s health. The United States Preventive Task Force’s recommendation against using the PSA blood test as a screening tool for prostate cancer (PCa) will bring additional harms to men. Since the beginning of PSA testing the mortality rate from prostate cancer has declined significantly, but there has been no improvement in the survival of men with metastatic disease.

Despite the new drug development we have seen for men with advanced prostate cancer, including the statistical improvement in survival advantages from these advanced drugs, a recent analysis showed that there is no improvement in overall or disease-specific survival in men with metastatic prostate cancer over a 20-year period.

“These data suggest that improvements in survival for patients with advanced disease have not contributed substantially to the observed drop in prostate cancer mortality over the PSA [prostate-specific antigen] era and that the stage migration secondary to PSA screening plays a more prominent role,” urologic oncologist Marc Dall’Era, MD, of the University of California Davis (UC Davis) Comprehensive Cancer Center, and colleagues wrote in Cancer.

PSA testing for prostate cancer screening began in the late 1980s. Dr. Dall’Era and colleagues have acknowledged that PCa mortality has declined by nearly 40% over the last 25 years in the U.S since the beginning of the use of PSA screening. However, they also said that the contribution of PSA screening for the early detection of PCa remains unclear and controversial. The group attempted to determine whether survival improvements over time in men with metastatic PCa have contributed to the decline in mortality.
By using the California Cancer Registry to identify 19,336 men aged 45 years and older who received an initial diagnosis of metastatic PCa from 1988 to 2009 the researchers corroborated previous studies showing a 65% reduction in those initially diagnosed with metastatic cancer since the introduction of PSA testing.

Men who received their diagnosis from 1988 through 1992 and from 1993 through 1998, however, had better overall survival than men who received their diagnosis in the most recent era. Disease-specific survival was no better for men who received their diagnosis most recently (2004 through 2009) than for men who received their diagnosis from 1988 through 1997.
“Because the PSA test detects cancer earlier, fewer men go on to be diagnosed with metastatic cancer,” Dr. Dall’Era explained in a statement from UC Davis. “However, there has been no survival improvement for men with metastatic disease to account for the overall mortality decline among all men with prostate cancer.”
According to Dr. Dall’Era the survival of men with metastatic PCa has not changed dramatically, whether PSA testing is responsible for the 40% drop in PCa mortality in general is unclear. These findings suggest that the benefits of PSA screening should continue to be evaluated before “sweeping policy recommendations against its use” are made.

I agree with the good doctors, given the information we have we should not be making policy changes that could again increase the number of men who will die from prostate cancer. There is adequate circumstantial evidence that the drop in mortality is the result of earlier diagnosis leading to less men becoming metastatic. Especially given that the mortality rate for men with metastatic disease has remained unchanged we need to find ways to prevent men from developing metastatic disease. PSA testing needs to continue, to cut back on the overall deaths while we also need to continue funding research that will cut the death rate in men with metastatic disease.

Joel T Nowak, M.A., M.S.W.