Dr Geo Espinosa on the Recent Change in Prostate Cancer Screening Guidelines

On May 8, 2018, the  United States Preventive Services Task Force (USPSTF)  issued new recommendations for prostate screening, published in Journal of the American Medical Association (JAMA), for prostate screening, stating “Clinicians should not conduct prostate cancer screening in men aged 55-69 years who do not ask for it (level C recommendation).” The groups also recommends against screening men over the age of 70. The new recommendations replace those from 2012, and upgrade the statement against routine screening from a D to a C. Today’s Practitioner asked contributor, Geo Espinosa, ND, an integrative urologist from NYU, to share his opinion on the decision. He likened it to “throwing out the baby with the bathwater.”

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The USPSTF is a government supported panel composed of national medical experts in primary care and researchers (no urologist or oncologist on the panel) who collectively review the evidence for what screening tools and treatments are most useful for patients.

The USPSTF has a grading system ranging from grade A, where the task force recommends for a service (screening or treatment) to grade D where the recommendation is against a service, and everything else in between. (see below chart).

In 2012 the United States Preventive Services Task Force (USPSTF) issued a reportopposing the use of PSA in screening for prostate cancer and gave a grade “D” recommendation, discouraging physicians to screen for prostate cancer and that there is more harm than good with the use of the PSA test.

Then two years later after further data review, the USPSTF graded PSA screening to a “C,” suggesting that the decision on whether or not to screen for prostate cancer with PSA test should be shared between the physician and patient and it should be used selectively in a case by case basis.

As published in the JAMA, the USPSTF concludes that there is a small overall benefit with the use of PSA in screening for prostate cancer, but continues to note that damages may occur during this screening process.

There is still a major age-related problem in this current recommendation because studies have predominantly included patients aged 55-70 years. Thus, the new USPSTF will not recommend PSA for men over 70 years nor for those under 55 years, which seems inadequate, given that it does not take into account clinical characteristics nor individual volition.

This new screening grade is important because the task force has an influence on how clinicians practice on what health insurance companies pay for.

Now Three Studies Driving Prostate Cancer Screening Controversy

Initially, the two main trials influencing the USPSTF’s grading on prostate cancer screening are The European Prostate Cancer Screening Trial (ERSPC) and The American Prostate Cancer Screening Trial (PLCO) study. Now there is a more recent study, the Cluster Randomized Trial of PSA Testing for Prostate Cancer (CAP) that reinforces the task force position on screening.

The Cluster Randomized Trial of PSA Testing for Prostate Cancer (CAP)

This British study was conducted in the United Kingdom, where about five hundred primary care practices in the United Kingdom were offered to screen men aged 50 to 69 years an invitation to a single PSA test (271 practices) and a control group that did not offer PSA testing (302 practices).

In an average of ten years follow-up, there was no all-cause mortality difference between the screened and the non-screened group. In other words, men who were screened for prostate cancer died from any cause, not just prostate cancer as much as men who were not screened at all. As one would expect, there was an increase in low-risk prostate cancer detection in the screening group in the CAP study.

The European Prostate Cancer Screening Trial (ERSPC)

The ERSPC randomized trial of about 160,000 men between 55 and 69 years for PSA screening or control without PSA where the PSA average to indicate a prostate biopsy is ≥ 3.0 ng/ml. The PSA test was taken, on average, only every four years. After monitoring for 11 years, screening reduced the risk of metastases by 41% and the chance of death from prostate cancer by 21%.

More recently, the European ERSPC study, now with almost 14 years of follow-up, confirmed that prostate cancer mortality in PSA screened patients decreased by 32% suggesting that as time goes on study subjects continued to be followed, there will be more benefit from PSA screening.

On the other hand, ERSPC trial continues to show a major problem with over diagnosing for prostate cancer screening with PSA of clinically insignificant tumors. In fact, in the ERSPC study, the finding of low-risk tumors (PSA less than10 ng/mL and Gleason score less than 6) was almost three times higher in the screened group than the control group.

The American Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO)

Lastly in the American Lung, Colorectal, and Ovarian Cancer Screening Trial Trial (PLCO) study randomized over 76,000 men aged 55 to 74 years for annual screening with PSA and rectal exam or control group with the “usual urological care,” that is, at the discretion of the urologist.

The PSA value used to indicate biopsy was ≥ 4.0 ng/mL. This study initially showed no mortality benefit for men who received PSA screening in comparison with those who did not.

The problem in the PLCO trial was the control group. Since “usual care” in the USA includes PSA, in this case almost 90% of the patients in the “usual care” group did the test compared to the randomized group. Therefore, it is no surprise that the rates of prostate cancer death were similar to the screening arm.

When researchers combined all the major prostate cancer screening studies, they did not find a significant decrease in prostate cancer-specific mortality except in the ERSPC which screening did indeed lower prostate cancer mortality. They concluded that “Harms associated with PSA-based screening and subsequent diagnostic evaluations are frequent, and moderate in severity. Over diagnosis and over treatment are common and are associated with treatment-related harms.”

The Takeaway from the USPSTF on Prostate Cancer Screening

The task force grade recommendation for prostate cancer screening stays at a “C”which mostly means that you, the patient, can dictate whether or not you want to be screened for prostate cancer. If you do not want a PSA test taken, then you can decline, and in theory, your physician should be fine with it.

Essentially, there is no grand change in the USPSTF recommendation from 2014, other than they are doubling down on their “C” grade reinforced by the CAP study.

The Dr. Geo’s Guide to Prostate Cancer Screening and Protection

I am all for patient empowerment and for men partnering with physicians to improve his health. Furthermore, many of my patients, naturally, since I am a holistic practitioner, want to avoid biopsies.

I don’t blame them. I don’t know anyone who gets excited about having their prostate poked 12+ times and have blood come out their urine and semen for up to two weeks.

The evidence is clear that most men with high PSA scores who get biopsied, do not have prostate cancer (what we call a false positive). It is also obvious, based on volumes of research that there is overtreatment of prostate cancer, meaning, most men with prostate cancer will not die from it making prostate cancer treated with either surgery or radiation obsolete.

Why not screen for prostate cancer and not treat if the outcome is low-grade disease?

Because that diagnosis is daunting to your brain. It’s the “cancer” word. In other words, the problem in many cases is the diagnosis itself – it provokes anxiety and unease – so rather than letting those feeling linger “taking it out” is what many men opt for.

The problem is not the PSA test. And ignorance is not bliss. Before the late 1980’s most men diagnosed with prostate cancer had advanced disease, and those numbers went down drastically after the commercial use of PSA test. The problem is how the PSA number is used (or abused). As the CAP study revealed, just one PSA number that is relatively high does not dictate you have prostate cancer or that a biopsy is needed.

When I partner with patients to determine if avoiding a prostate biopsy is the right for them, we look at:

• Age
• Family history
• Race
• PSA relative to age
• PSA free percentage
• PSA density
• Blood test 4K score
• Urine test Select MDx.

Then we consider a few “ifs.”

1. If most of the results from testing indicate suspicious prostate cells, then we look into getting a 3-Tesla MRI. Still, no biopsy needed up to this point.
2. If the MRI highly suggested suspicious cells, typically of Gleason 7 or higher, then I would recommend a biopsy, but not a random ultrasound guided one, a targeted MR fusion biopsy.

The bottom line is how a physician uses a PSA test matters most, as imperfect of a biomarker for prostate cancer screening as it is, it saves lives. At a minimum, an elevated PSA can tell you if something wrong in the prostate, even if it’s not cancer, maybe inflammation or other benign development.

The ultimate goal of prostate cancer screening is this:

1. Find a cost-efficient method of locating tumors that have the most life-threatening potential.
2. Leave tumors that are not deadly alone, or better yet, not find them in the first place.
3. Have a treatment that can remove the possibly deadly cancer without sacrificing quality of life.
4. The methods of the screening I highlight above provide the best chance of accomplishing the ultimate goal for prostate cancer screening.

Also, prevention is the best medicine.

When I say prevention, I also mean prostate cancer recurrence prevention or, if it returns, preventing spreading of cancer.

Nutrition and Lifestyle is Real Medicine.

Overall, Here are My Recommendations to Patients:

• Eat protective foods. A plant-based, Mediterranean method of eating is protective, and it’s the cornerstone of the CaPLESS method of eating.
• Exercise four hours a week with moderate intensity.
• Consume selected, targeted supplements from companies that exceed governmental quality manufacturing practices. My favorite supplements for ultimate protection are what I call my one-two punch: ImmunoPCTN and GDtoxSel.

This article is an edited version of a blog post by Dr Geo Espinosa at DrGeo.com. Used with permission. Dr. Geo Espinosa is a renowned naturopathic doctor recognized as an authority in holistic and functional urology. Dr. Geo is Clinical Assistant Professor at New York University Langone Medical Center (NYULMC)  – Department of Urology where he is the director of the Integrative and Functional Urology Center. He is the author of the popular prostate cancer book: Thrive, Don’t Only Survive and co-authored numerous books on natural medicine in urology and men’s health. Dr. Geo is the Chief Medical Officer and formulator of XY Wellness, LLC and lectures internationally on the application of science-based nutritional medicine in urology. On his time off from work, he enjoys researching, writing on his popular blog, DrGeo.com and spending time with his wife, Johanna, and three kids.