By Dr Navin C. Shah, MD, MS, FACS, FICS, FACIP
Prostate cancer (PCa) is one of the most commonly diagnosed cancers in men and is the among the top three causes of cancer death in men in the United States. It usually occurs after 50 years of age and that is why PCa screening in men over 50 years of age has been the norm since the advent of the blood test to measure Prostate Specific Antigen (PSA). PCa screening – which includes both the PSA test and a Digital Rectal Exam (DRE) to feel abnormalities in the prostate – saves lives. In the pre-PSA period (prior to 1990) almost 30% of PCa patients had metastatic cancer when first diagnosed, while in 2014, due to PCa screening, the rate of metastasis at first diagnosis was less than 5%. Between the early 1990s and 2012 when PCa screening was common, PCa mortality was reduced by 50%.
In 2012 the US Preventative Services Task Force recommended against PCa screening. This decision was based on studies that had less than 5% of men of African-American ancestry as participants, while the percentage of men of African-American ancestry in the US is around 15%. Rates of prostate cancer are significantly higher among men of African-American ancestry than in white men (and this is why studies that include primarily white men will always understate the benefits of PCa screening). In 2014 the American Association of Retired Persons (AARP) declared that PSA screening is overused and unnecessary and hence recommended that men skip the PSA test. In 2016 the Centers for Medicare and Medicaid Services (CMS) went so far as to issue a policy that any physician who offered PCa screening to men 70 years and older would be categorized as a low quality physician! (The same year, a major medical center, Duke University, made a bold move to buck the USPSTF recommendation and offered a PCa screening at no cost.) Sixteen physician Congressmen opposed the CMS policy in writing and after a few months the CMS retracted the policy temporarily.
In 2018 the USPSTF awarded grade” C” (may or may not benefit) to PCa screening and restricted it to men 55 to 69 years old. The Task Force continued their recommendation against PCa screening of men 70 years and older. However, the life expectancy for men in the US is about 84 years of age, so by denying the over- 70 set the right to PCa screening, more healthy elderly men will be put at risk for advanced prostate cancer.
The combination of USPSTF, CMS and AARP policy has resulted in some 50% of internists and family physicians failing to offer PCa screening to men, and especially to men 70 years and older in the last 4 years.
From 2014 to 2019 radiation oncologist Dr Vladimir loffe and I published six papers and wrote nine letters to the Editor in the US Urology Journals about PCa and PCa screening. Our goal has been to have PCa screening offered to men over 50 years, especially for high risk men such as men of African-American ancestry, men with a family history of PCa and men 70 years and older. Men of African-American ancestry and men with a family history of PCa are almost doubly affected compared to all men of a similar age. To date, we have been largely unsuccessful, except that recently the CMS sent me a letter in which it is stated that they will cover an annual PCa screening in male Medicare participants 50 years and older.
Treatment of early stage PCa offers a cure in most cases. The five year survival of an individual treated early is 99%, while prostate cancer that metastasizes is enormously costly to treat and death is almost certain. Currently, a PSA test only costs about $22. Yearly PCa screening will drastically reduce PCa morbidity, mortality and also the cost of PCa care.
Dr Navin C. Shah is the Director of Medical Education at MidAtlantic Urology Associates, Greenbelt, MD, where he practices with 10 other board-certified urologists. He is a Diplomate of the American Board of Urology and the American Board of Quality Assurance and Utilization Review Physicians.