Thomas Moody, MD, an urologist now retired from Urology Centers of Alabama, worries about the long-term implications of this recommendation as well as the reversal of a trend that has seen a reduction in deaths due to prostate cancer over the past few decades. The reversal is attributed to widespread use of the prostate cancer specific antigen (PSA) for prostate screening since the mid-1980s.
Also attributed to regular screenings is a significant decline in the mortality among black men in Alabama from prostate cancer. “The trend in Alabama coincides with a sustained effort by the Alabama Department of Public Health and the Urology Health Foundation to conduct regular screenings among high-risk populations, especially in the Black Belt region of our state,” Moody says. “And I believe that sustained effort has paid off.”
That same effort also has helped reduce a disparity in prostate cancer mortality between whites and blacks in that area where the state of Alabama ranked number one in the nation in deaths from prostate cancer among blacks. “The trend of a general decline in mortality is nationwide, but the dramatic decrease in the mortality of blacks in Alabama is ahead of the national average,” Moody says. “The effort also has eliminated the disparity in early stage diagnosis between the races.”
Prostate cancer is the most common cancer in American men after skin cancer and is the second leading cause of cancer after lung cancer. One in six men in the United States will have prostate cancer during their lifetimes. Since using PSA screening, the death rate from prostate cancer has been reduced by 40 percent, “an encouraging trend that has continued nationwide,” Moody says.
However, Moody believes that the task force recommendation has resulted in a widespread reduction in prostate cancer screenings. The Medicare claims database of RealTime Medicare Data over the 2011-2014 period shows an aggregate decline of almost 11 percent in PSA screenings among Medicare beneficiaries in 18 states studied, and there has been as much as a 25 percent decline in some states. “As screenings decline, the ‘incidence’ of prostate cancer may also appear to have declined, but prostate cancer has not gone away. It is just not being diagnosed at the same rate,” Moody says. “If this trend continues, I anticipate there will be a large group of men who will not have the benefit of early diagnosis, and that by the time this group of men discovers their disease, it will not be in an early stage and probably will not be curable.”
This task force, Moody says, is the same one that, a few years ago, made the recommendation that women over 40 not have mammograms. “The breast cancer community had a ground swell of support to fight that recommendation, but we haven’t had the same success related to prostate cancer,” he says, “even though statistics are about the same but with probably more deaths attributed to prostate cancer.”
While the task force recommendation is not a mandate, many have taken its recommendation, including the American Urological Association which has reduced guidelines for prostate cancer screening. “New guidelines state that white men with no history of prostate cancer should be screened beginning at age 55. If we followed that recommendation, many men ages 40 to 54 with prostate cancer would have been missed,” Moody says.
Created in 1984 and authorized by the U.S. Congress, the task force is an independent group of national experts in prevention and evidence-based medicine that works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services or preventive medications. The task force – which does not include an urologist, oncologist or any physician who treats cancer – cited over-diagnosis, over-treatment, complications of diagnostic procedures, complications of active treatment, and cost involved as reasons to stop prostate screenings.
“The statistic that nobody disagrees with is the 40 percent decline in mortality. Frankly, it’s baffling,” Moody says. “I agree we need to address concerns with over-diagnosis and treatment, but we don’t need to stop the screenings. A man should have the option to be screened and to have a biopsy. That decision is best made between a man and his physician, not some group in Washington, D.C. that has no first-hand experience in treating this disease.”
Catching the disease early is beneficial to all involved, Moody points out. “Any problem is easier to solve if you catch it early. Treatment of prostate cancer costs less when caught earlier, not to mention the reduction in suffering,” he says. “Unfortunately, a lot of primary care physicians have taken this recommendation to heart and are not screening for prostate cancer. Statistics show the amount of screening is down significantly, especially in Medicare patients.”
Moody reiterates that the task force can only recommend discontinuing PSA screening, it can’t stop it. In fact, the Alabama legislature passed a law in 2007 to require insurance companies in the state to pay for physician-ordered PSA screening. To stop that coverage, the law would have to be changed. “We plan to continue screening our patients through our non-profit Urology Health Foundation, and I encourage all physicians to continue checking PSAs and prostates,” he says. “The future of prostate cancer management should not be to ignore the disease, but to address it so that the significant advances in mortality can be preserved while also improving the quality of life for men with prostate cancer.”
