In the early 1990s, the annual prostate-specific antigen (PSA) screening test for men 50 years of age and older reduced prostate cancer (PCa) mortality by 50%. Unfortunately, in 2012, based on a flawed PCa screening trial (Screening for Prostate Cancer in Older Patients [PLCO], NCT00002540), the United States Preventive Services Task Force (USPSTF) recommended against PCa screening.
By 2018, the USPSTF upgraded the recommendation for PSA-based PCa screening from grade D to C (but maintained a grade D for men 70 years and older). These recommendations are largely followed by frontline primary care physicians, and currently 50% of primary care doctors are not offering their patients annual PCa screening.
The US data indicate that the lack of PCa screening has increased the number of patients with PCa, PCa metastasis, and PCa mortality, especially in men 70 years and older. The American Cancer Society reported 161,360 new cases of PCa and 26,730 deaths due to PCa in 2017 compared to 191,930 new cases and 33,330 deaths in 2020, respectively.
In 2010, Medicare spent $11.8 billion on PCa treatment which increased to 15.3 billion by 2018, largely due to treatment of advanced PCa. As PCa specialists, we have reviewed our local experience with PCa and have published our results in US urology peer reviewed journals (7 papers and 13 letters).
Our most recent paper, A trend toward aggressive prostate cancer,1 showed that the number of prostate biopsies have decreased by 45% while the diagnosis of PCa has increased threefold. Our data (and other US data) have highlighted 3 highrisk groups for PCa—African American (AA) men, men with a family history of PCa and healthy men age 70 and above.
The PLCO PCa screening randomized trial on which the USPSTF based its recommendations against PSA-based PCa screening was contaminated (90% of the men in the non-screening arm were screened) and had only 4% AA men. In the US, AA men represent about 12% of the population and in large cities represent over 30%.
Based on our data and that of other US groups, we strongly believe that annual PCa screening (PSA and digital rectal exam) should be offered to all men 55 years and older. PCa screening should especially be offered to high-risk men—AA men, men with a family history of PCa, and healthy men 70 years and older. Currently, due to enhanced risk assessment tools (both MRI imaging and genetic tests) and the ability to offer men active surveillance, overtreatment of PCa has been significantly reduced. According to current Medicare policy, Medicare covers an annual PSA-based PCa screening for men 50 years and older.
Our goal is to highlight this coverage policy so that PSA-based PCa screening can be increased in order to diagnose and cure early PCa, thereby reducing PCa morbidity, mortality, and cost associated with late-stage treatment. Navin Shah, MD; and Vladimir Ioffe, MD / Greenbelt, Maryland REFERENCE 1. Shah N, Ioffe V. A trend toward aggressive prostate cancer. Rev Urol. 2020;2
(Picture: Medicare FAQ)