To PSA or Not to PSA: We May Have a Surprising Answer

Posted by Mark Abramowicz, M.D.

The next issue of The Medical Letter will address this question, which has come up again now because the US Preventive Services Task Force (USPSTF) recommended in the current Annals of Internal Medicine that men of any age should not be screened for prostate cancer with a PSA. At almost the same time an article appeared in The New England Journal of Medicine reporting that a controlled trial of radical prostatectomy (versus observation) in patients with early localized prostate cancer found no benefit from the operation in overall mortality or prostate cancer mortality. That would seem to close the books on this issue, but….

An editorial in the same issue of The New England Journal pointed out that the radical prostatectomy trial was underpowered, i.e., it did not enroll enough patients to detect even a relatively large clinical effect. Nevertheless, in a subset analysis, the authors of the controlled trial did find significant differences between the prostatectomy and control groups in overall mortality, prostate cancer mortality, and development of bone metastases among one group of men: those whose PSA was higher than 10 ng/ml. Subset analyses are often dismissed as not quite kosher, but perhaps not when they show a significant difference in the primary and secondary endpoints in a high-risk group in an underpowered study. And we would all agree that there is no way to know if you have a PSA higher than 10 without doing a PSA.

More to come in the next issue of The Medical Letter.

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