Many health care provision systems don't invest in screening tests or other early-detection schemes, or they do make them available, but don't invest in raising awareness of their availability. I'm actually now at the age where I should start thinking about "What new periodic tests/checkups should you introduce within the next 5 years?" ... and at this point I'm still clueless, except that I know that at around 50 I should start getting my PSA checked.
Beware: more testing does not imply better outcomes. There are many situations where a test result may show something that apparently "need to be addressed", but the side effects and problems caused by "addressing" that result is, on average, worse than the result of never having tested in the first place.
Of course, many tests are valuable, with results that can lead to effective treatment. But, it's hard to know which is which without significant study.
I don't know about "should", it's a conversation you should have without your doctor (at age 55-69) as it's not without risks (2/3 false positives, if you need a biopsy literature is 3% infection rate requiring hospitalization. Although the advent of prostate MRI may obviate some biopsies, it's still center specific. This will probably change but we don't have enough evidence yet to support this as screening (or to not do a random biopsy if the MRI is negative for clinically significant cancer). In any case most prostate cancers detected this way are low grade and watched with active surveillance anyway.
There is medium evidence that PSA screening does not improve overall mortality, strong evidence of harms and moderate evidence to support early detection for overall weak recommendations (grade C) to consider screening in 55-69 (50 in US and EU) for patients who decide they want it after shared decision making[0-3].
I definitely would not say that everyone should, it's a personal decision after a discussion. As a physician I personally wouldn't.
Note the guidelines differ for carriers of certain genetic mutations or are high risk.
> Many health care provision systems don't invest in screening tests or other early-detection schemes, or they do make them available, but don't invest in raising awareness of their availability.
This is a stretch, I'm not sure where you're living but this is not true in US, to a minimal extent in Canada (we still require GPs to send requisitions for mammograms in patients age 40-49 but the screening program covers 50 in spite of newer guidelines but we definitely provide age-approriate screening oral), and should not be in major European countries based on their own guidelines.
The reason no one is pushing PSA screening on you is because most physicians don't believe it and the recommendations themselves are very weak, only in patients who themselves desire it.
It's a screening blood test which, when positive, makes you go get a more serious exam. So the effect of a false positive is that you get, say, an MRI. So at worst, 3x the required number of MRIs will be taken due to such screening. It's not even excessive irradiation of people.
> we don't have enough evidence yet to support this as screening
For the general population, you may be right, I'm not an epidemiologist. For people with a strong family history of prostate cancer it's a different story. The point is the different people need to consider different checkups based on their personal medical situation and family history.
> literature is 3% infection rate requiring hospitalization
Prostate cancer rarely requires hospitalization - unless you do nothing about it for so long that it metastasizes. Otherwise, treatment is typically as an outpatient. So that metric is also not really relevant I would say.
> PSA screening does not improve overall mortality
Again, wrong metric. You can wait until symptoms appear and still have very low chances of mortality, but the damage due to treatment is much more significant.
The point is to catch the prostate cancer early enough, that treatment can get rid of it with very little damage to surrounding tissue.
> this is not true in US, to a minimal extent in Canada
In the US, a large part of the population is not even cared for medically: There is no universal automatic coverage of residents.
Also - medical health providers can easily bring up arguments such as those you have brought up, to avoid screening even conditionally for various health risks.
So I believe you have an overly lenient evaluation of screening policies.
> The reason no one is pushing PSA screening on you is because most physicians don't believe it
Based on your questionable choice of arguments and facts, I am not very credulous that this statement is indeed true, and that a proper survey with the proper question and relevant information has been put to the relevant physicians.
At any rate, at least first link you gave, to the description of the issue by the AUA, is very saddening, because they also mis-represent the dilemma, and apparently aren't bothered about people's quality of life as long as they don't die. I've been told otherwise by more than one Eurologist, and with an insistence to the degree of making me set a phone calendar appointment several years from now to remind me to go get my first PSA blood test.
> It's a screening blood test which, when positive, makes you go get a more serious exam. So the effect of a false positive is that you get, say, an MRI. So at worst, 3x the required number of MRIs will be taken due to such screening. It's not even excessive irradiation of people.
Actually it’s not, prostate MRI is still new and a positive PSA with negative MRI will still get a biopsy, some “centers of excellence” may practice differently but I trained in the highest volume prostate MRI center in North America and this is certainly not the case at the moment. There is insufficient evidence to support your claim that we can stop at MRI at this time.
> For people with a strong family history of prostate cancer it's a different story. The point is the different people need to consider different checkups based on their personal medical situation and family history.
This is included in our guidelines which are intended for average risk patients. There is insufficient evidence to come down hard for high risk patients (1st degree relative < 65 at diagnosis being one) hence why it’s a shared decision making process. Most people screen this group of patients in my practice experience.
> Prostate cancer rarely requires hospitalization
This is the hospitalization rate for BIOPSY. Even metastatic prostate cancer rarely requires hospitalization.
> The point is to catch the prostate cancer early enough, that treatment can get rid of it with very little damage to surrounding tissue.
I’m not sure how you think this is true. Robotic prostatectomies and curative intent radiation are the standard of care for organ defined disease (representing 90-95% of cases detected WITHOUT screening, obviously higher with) and both carry significant risks of impotence and incotinence.
First line treatment of disseminated disease is androgen deprivation which actually isn’t as morbid as you claim.
> Also - medical health providers can easily bring up arguments such as those you have brought up, to avoid screening even conditionally for various health risks.
So I believe you have an overly lenient evaluation of screening policies.
Every doctor practices evidence based medicine. The USPTF, AUA and EUA/ESUR all recommend against routine screening. There is a proposal right now in Europe to re-evaluate this recommendation given the emergence of prostate MRI and potential to avoid biopsy but again we’re getting into experimental/emerging areas hence why this is a /discussion/ with your provider and participating in /shared decision making/ rather than telling everyone “go get your PSA screen”.
I’m not sure why you’re calling every major societal guideline a questionable choice of evidence? We practice evidence based medicine not science based medicine.
PSA screening WAS a thing until studies came out showing harm and the USPTF changed their recommendation.
Some urologist like following PSA in average-risk patients because it’s a quick and easy billing visit. I assure you the physician societies all consider patient morbidity when making these recommendations, overall mortality is still the most important metric in medical research because it is the least subjective to bias. As discussed above the treatment options for disseminated disease have low morbidity and the treatment options for confined disease have similar-higher morbidity.
What is saddening about the AUA perspective or the dilemma the medical society is failing to understand? Can you provide any evidence to suggest prostate cancer screening reduces morbidity?
Many health care provision systems don't invest in screening tests or other early-detection schemes, or they do make them available, but don't invest in raising awareness of their availability. I'm actually now at the age where I should start thinking about "What new periodic tests/checkups should you introduce within the next 5 years?" ... and at this point I'm still clueless, except that I know that at around 50 I should start getting my PSA checked.