PSA recommendations - is it sexism?

Sorry for the significant delay in blog posts.  It's been a long couple of months at DuPage Family Medicine.  We were forced to terminate the services of a long-time employee, all while having to deal with a 6+ week disruption in our phone service.  It's been a stressful couple of months, but we are starting to see the light at the end of the tunnel, and it's time for me to start writing again.

Last week, the U.S. Preventive Services Task Force (USPSTF) recommended against the use of prostate-specific antigen (PSA) testing for routine screening for prostate cancer.  The USPSTF states that the risks of screening outweigh the benefits, arguing that certain treatments for prostate cancer can actually increase mortality.  Other arguments against PSA testing include the morbidity associated with the diagnosis and treatment of prostate cancer, such as impotence and incontinence, as well as the emotional stress a false-positive test can cause the patient.

In my practice, I begin doing prostate exams at age 40 on all men.  PSA testing usually begins at age 50 for low risk men.  For higher risk patients, I begin screening at age 45. These patients are men of African-American heritage and men who have a family history of prostate cancer in a first degree relative (brothers or father).  Using these guidelines, I have diagnosed 7 men with prostate cancer under the age of 50, about one patient in this age group every 2 years.

A few years ago, the USPSTF recommended against the use of annual mammography to screen for breast cancer in women.   There was immediate backlash from the public and physician groups.  That recommendation was based on statistics and data that showed that annual testing led to more procedures, and didn't necessarily improve outcomes, almost exactly the same argument against PSA testing.  The public outcry over the mammogram recommendations was loud and clear, but unfortunately, there hasn't been the same kind of backlash against the new PSA recommendations.  I find that extremely disappointing.

It is unfair to recommend against the only screening test men have for prostate cancer, even if it has drawbacks, when a similarly mediocre screening test continues to be a mainstay of diagnosis for breast cancer in women.   We need to support researchers to find better screening tools for all cancers, not just prostate and breast.  Specifically speaking of prostate cancer, if researchers can give us a test that can tell the difference between a slow growing cancer and an aggressive one, we can eliminate a large number of invasive surgeries, significantly decreasing the morbidity of excessive treatment.

I respect the USPSTF and most of their recommendations.  They tend to be conservative, with recommendations that are based on the data. The problem with the new PSA recommendation is that we don't have an alternative.  Just because some of the treatments for prostate cancer lead to increased morbidity doesn't mean you eliminate the use of the only screening test we have available.

I am planning on implementing the recommendations as follows.  For any patient with an abnormal exam (enlargement of gland, asymmetry, etc), they will continue to get annual PSA levels independent of age.  For low risk patients and men with stable prostate exams, I will do PSA levels every 2 years.  All of this will be dependent on the patients comfort level.  If they want an annual test, then we'll order it.

Recommending against PSA testing, yet continuing to recommend mammography, seems a bit, dare I say, sexist.  But then again, I'm a guy.