PSA: A Shared Decision

“As a urologic oncologist and health services researcher, I am interested in the downstream effects of changes in health policy […] on population-level outcomes for men at risk for prostate cancer and other urologic cancers.” Christopher Filson, Assistant Professor of Urology at Emory University School of Medicine, acknowledges the difficulty of selecting populations for prostate cancer screening using prostate-specific antigen (PSA), and of limiting screening to those who will reap the greatest benefit. The outcome? A reduction in overall testing – as observed in a recent study (1) – and, hopefully, more appropriate management for both those who are screened and those who are not.

But is a decrease in prostate cancer screening a bad thing? Filson doesn’t think so. “The controversies surrounding prostate cancer screening with PSA testing stem from the inherent complexity of the subject matter, as well as strong vested interests and prior biases from people involved in the conversation,” he says. It’s hard to deny the strong association between a large population-level decrease in prostate cancer mortality in the United States after broad adoption of PSA screening – although, Filson adds, some do not admit to a causal linkage between the two. Continued efforts to identify those who would benefit most from PSA screening (such as those with strong family history) will reduce unnecessary testing and treatment in those with less to gain (such as men over 75 years of age).

Some, however, fear that screening fewer men may lead to underdiagnosis. Filson says, “There should be continued efforts into accurately figuring out how to assign risk of prostate cancer for men considering screening. This includes finding who may be at higher or much lower risk.” He also highlights the importance of considering that some patients may have graver concerns – such as more severe medical conditions – that would increase the likelihood of their death within five years of prostate cancer diagnosis, making treatment unnecessary and sometimes ineffective.

To work properly, though, this common-sense approach needs buy-in from all parties. “The discussion around PSA screening should take place between patients, partners, and providers, keeping the risks and benefits of different approaches in mind. It should be a multidisciplinary effort between health services researchers, epidemiologists, urologists, radiation oncologists, primary care physicians, and others. Advisory bodies and professional groups should continue to craft guidelines related to PSA screening and emphasize the importance of shared decision-making.”