Prostate cancer and primary care: What physicians should know

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Prostate cancer is a leading cause of cancer death in American men, and it’s time to revisit the guidelines to test for it, said the leader of a national urology group.

This fall, the U.S. Preventive Services Task Force (USPSTF) solicited comments about its “Prostate Cancer: Screening” recommendation. It’s an early step in the review process that could lead to changes to the recommendation dating from 2018.

Then, USPSTF gave a “C” grade to screening men aged 55 to 69, so the decision to be screened for prostate cancer should be an individual one. The Task Force recommended against prostate specific antigen-based (PSA) screening for men aged 70 years or older.

That 2018 recommendation updated another from 2012, when USPSTF recommended against PSA testing for prostate cancer for men of all ages.

Evan R. Goldfischer, MD, MBA, CPI

From 2007 to 2014, less screening led to a decline in prostate cancer diagnoses. Since 2014, incidence rates are growing, according to the American Cancer Society.

Prostate cancer rates are rising, especially among Black men, even though screening and treatment options have gotten better in recent years. That makes it time to revisit the USPSTF guidance, said Evan R. Goldfischer, MD, MBA, CPI, president of LUGPA (formerly the Large Urology Group Practice Group Association).

One thing hasn’t changed: Early detection is key for physicians and patients to fight cancer.

“In general, with cancer, the earlier you detect it, the better the odds are that you're going to cure it and the more options he has for treatment,” Goldfischer said. “Once it gets past localized and becomes metastatic, the options become fewer and the prognosis becomes worse. And that's true for prostate cancer as well.”

Goldfischer spoke to Medical Economics about what LUGPA wants primary care physicians to know about the status of prostate cancer diagnosis and treatment. This interview has been edited for length and clarity.

The LUGPA comments to USPSTF also are available online.

Medical Economics: Can you discuss the current recommendation for prostate cancer screening? Has the sensitivity of the PSA test gotten better over the years?

Evan R. Goldfischer, MD, MBA, CPI: It's the best test we have. It's not perfect, but I think we're much wiser in how we use it right now. Back when I was training, just about every man got a PSA and just about everybody who was diagnosed with cancer got treated. I think we were guilty in the early 2000s and 1990s of overdiagnosing and overtreating prostate cancer. We realize now that most cancers take a while to kill you, so do you really need to screen a 95-year-old man who's diabetic, who’s had two heart attacks and stroke? Probably not. He's not the kind of guy who's going to die from prostate cancer. On the other hand, do you really need to treat someone with a one very small focus of low-grade prostate cancer, or is it safe to watch?

The United States Preventive Services Task Force is not a government agency. But the name implies that it is, a lot of people think that it is, and it often carries the weight of government agency. So, they modified their recommendation in 2018 to say, you know what, we shouldn’t still do mass screenings, but certainly the primary care doctor should have a discussion with each patient and see if screening is the right move for them. When you typically get an elevated PSA, you don't know if that means cancer or no cancer until you do a biopsy. The biopsy often tells you, is this kind of a low-grade, a medium-grade or high-grade cancer that’s very aggressive? We also didn't have in 2012 all the genetic tests that we have right now, that tell you is this a very aggressive cancer that you need to treat, or is this something you could watch and wait? So to me – and again, I'm a urologist, so I'm a little bit biased – knowledge is power. I still think it's important to get a PSA blood test, I still think it's important to do the biopsy, if necessary. Then you have the discussion with the patients – and this is more of a urologic discussion rather than a primary care discussion – of, what are their goals in life? What is their health? What is their genetic history? What is the longevity in their family? And what are the pros and cons of treatment? And once you have that conversation, and each patient is different, then you can arrive at the right decision for the patient. But you don't know until you get that PSA.

One of the problems that's happened with the 2012 recommendation is, we know that Black men get prostate cancer at a much higher rate than Caucasians and we know that they present often with more advanced disease and they're about twice as likely to die from the disease. Because of the social determinants of health, black men often have lower income, live in poor areas, lack of access to medical care, lack of advanced education, lack of social contacts. They're the ones who are mostly getting left out of the screening. And that's why their rate of diagnosis of advanced disease has largely increased because the 2012 USPS Task Force did not take into the social determinants of health into their recommendations.

Medical Economics: Can you talk about the technology that is going into the testing process, the diagnostic process? It sounds like that's good and getting better.

Evan R. Goldfischer, MD, MBA, CPI: Exactly. You know, we can often profile based on your genetics, how aggressive your tumor is, and if it's likely to become a problem and kill you. And we also look for things like the BRCA1 and BRCA2 genes, which may predispose you to prostate cancer, you may have had a genetic risk, didn't know about it. That is also information you have for your kids. If you have a son and you have a BRCA mutation, you may want to have him screened a little bit earlier, or have him get genetically tested and certainly if you have a daughter and you're carrying that BRCA gene, you want her to get tested for that gene to see she's at risk for breast cancer. So, the genetic tests have really added a lot of power to the urologist in terms of recommendations. And then the MRI – most prostate cancers can't be felt, but the MRI has now given us an ability to see, if you will, prostate cancer that you can't feel in the prostate. And as of about a year and a half ago, we have a new test, the PSMA test, prostate specific membrane antigen chest. After you're diagnosed, this is a very, very, very sensitive test to determine has the cancer left the prostate and are you truly a candidate for radical treatment with surgery or radiation? Or is this something that's left the prostate and now we need to think about hormone therapy, chemotherapy and other things like that? So, the advances I'd say since 2012, have been exponential, not only in terms of diagnostics, but we also have a lot of treatments now for advanced prostate cancer that we didn't have back then. And in many cases, we can take what used to be a lethal diagnosis and turn it into a chronic disease and treat it and hopefully you die of something else and not of your prostate cancer, but you die with your prostate cancer. And we continue to have more and more advances coming down the pike. So the glass is half full, so to speak, in regards to diagnosis, prognosis and treatment for prostate cancer. But again, if you don't know you have it, you don't get screened, you can't start to go down this algorithm.

Medical Economics: What would you like to see from the U.S. Preventive Services Task Force?

Evan R. Goldfischer, MD, MBA, CPI: I'd like to see them make another revision to their recommendations that they did in 2018. I’d like to see the U.S. Preventive Services Task Force say, you know what, it's more than just having a discussion now, that we need to really offer the test to every male patient and let them decide if it's right for them. But it really should be offered to everybody. We shouldn't have academies denying this opportunity or denying this information to patients, especially the most at-risk patients, Black Americans who are really suffering because they're not getting access to care and they're not getting tests done. You saw this is what happened years ago when the U.S. Preventive Services Task Force wanted us to deny care to women for screening for breast cancer. The women went up in arms very quickly and their recommendations were retracted. Men are not quite as vocal about their health as women and don't have the same advocacy in place for themselves, and that's why I think it hasn't happened yet for men.

Medical Economics: There are a lot of studies and a lot of advocacy about disparities and inequities in health care. Especially if Black American men are the ones who are most at risk, why still the disparity? Why hasn't that caught up yet, if people are rightly voicing concerns about equity in health care?

Evan R. Goldfischer, MD, MBA, CPI: Not enough people are voicing that concern and not voicing it loudly enough. That's why we haven't corrected the equity. We have a ways to go. The Prostate-Specific Antigen Screening for High-risk Insured Men Act (PSA Screening for HIM Act) is a bipartisan proposal right now, it’s House Resolution 1826. Unfortunately, the House (of Representatives) is nonfunctional right now. But this is a bipartisan proposal, so it's a miracle that actually everybody agreed on this, at this point. This is specifically focused on Black patients and patients with family history of the disease. And this is a bill that says hey, you have to cover PSAs and you have to cover it without any coinsurance or out-of-pocket costs, that you have to do it. And then the Reducing Hereditary Cancer Act would expand Medicare to cover screening for individuals with a family history of hereditary cancer, not just prostate cancer, and it covered the associated coverage of risk-reducing surgeries and screenings and whatever else you need. So, there are some bills in Congress right now with bipartisan support. Hopefully, they will pass.

Medical Economics: With congressional legislation, do we run the risk of the pendulum swinging the other way, back to overtesting, overdiagnosis?

Evan R. Goldfischer, MD, MBA, CPI: No, I don't think the question is of overtesting, of overdiagnosis. I think the question is in overtreatment. Treating prostate cancer is really a urological specialty, maybe a little bit of oncology, but really mostly urologists are the ones who are treating this. I think the urologists in practice now and the ones that are coming out of training have become a lot more responsible in their use of technology and treatments, so that a lot more patients are undergoing active surveillance than ever before. So, I think we've become much more responsible as a profession.