Wednesday, July 11, 2012

The end of the line on PSA screening

In the summer of 2007, then-U.S. Preventive Services Task Force member Russ Harris, MD, MPH approached me about taking on what he suggested would be a fairly quick and straightfoward project: summarizing the small amount of medical literature on the benefits and harms of the prostate-specific antigen (PSA) test that is commonly used to screen asymptomatic men for prostate cancer. Little did I know that this research and its implications would dominate the next five years of my career. There would be some good moments (my published systematic review of the topic was honored as AHRQ's Article of the Year award in 2009) as well as many bad ones (encapsulated in this series of posts that recount the reasons for my subsequent resignation from the Agency in 2010). This year, the USPSTF finally confirmed what had become clear to me and many other scholars of PSA screening: the test's harms outweigh its benefits for the vast majority of men, and therefore it should not be recommended.

Although the Medicare program and private insurance plans continue to pay for the PSA test, there is reason to hope that the new recommendation will eventually change medical practice. Despite the backlash that greeted the USPSTF's 2009 recommendation for individualized decision-making regarding mammography for women in their 40s, recent national data has demonstrated a 6 percent decline in screening rates in this age group - modest but notable evidence that more women are making thoughtful screening decisions that reflect their personal values and preferences. Based on the USPSTF's assessment, I now tell older male patients that the harms of the PSA test's downstream consequences are very likely to outweigh any potential health benefits. Some still request the test, but such requests are becoming less common.

During the past five years, I have given countless lectures and participated in many public debates about PSA screening. I recently agreed to address the subject once more in October at a panel discussion sponsored by the Department of Health Policy and Management of the Johns Hopkins University Bloomberg School of Public Health (where I am an adjunct instructor). And I have decided that for me, that event will be the end of the line for public speaking about PSA screening, at least until there is more evidence to discuss. It's time for me to move on, personally and professionally. Nonetheless, I hope that others will take up the essential task of communicating the flaws of this test to physicians and the public, so that someday we may reach the end of the line on PSA screening itself.


  1. Thanks for all your good work on this, Dr. Lin.

  2. Thanks, Kenny. Your hard work is worth it. Not a week goes by I don't mention you when discussing PSA testing with patients, most who choose to no longer get tested. Now if I can just get it removed as an overdue health maintenance item in our EMR. Keep fighting the fight.

  3. However the urologists are hard at work still trying to convince the public that PSA is invaluable.

  4. Here's an editorial in the Lancet ("Prostate cancer: send away the PSA?") regarding the negative results of the PIVOT trial that is well worth reading:

    A sample:

    "In the early 21st century doctors often find themselves asking not what investigations and interventions can be done, but what should be done. As in the case of PSA screening, there is a real risk that intervention may be worse than observation. The current buzz around medicine's 'creative destruction' via genomic sequencing and smartphones constantly monitoring physical parameters raises the possibility that medicine might yet snatch defeat from the jaws of victory. Would constant checking for disease be reassuring, or would it interfere with the actual business of living? The empowerment of patients with information, where possible from appropriate physical tests, is to be encouraged: but striving after a technology-driven, purely biomedical model of perfect physical health is no form of empowerment at all. The PIVOT trial is a timely reminder of medicine's—and life's—imperfections. To the Hippocratic Oath might be added: I will not request an investigation unless I am confident that the answer, and the actions I take on its basis, will substantially improve my patient's life."