Routine PSA:Evaluating the Evidence

Sheldon Greenfield, MDHealth Policy Research InstituteUniversity of California, Irvine

October 23, 2012

Management of Intellectual Conflict of Interest

“Academic activities that create the potential for an attachment to a specific point of view that could unduly affect an individual’s judgment about a specific recommendation”

- Clinical Practice Guidelines We Can Trust Institute of Medicine, 2011

“Conclusions: Analyses after 2 additional years of follow-up consolidated our previous finding that PSA-based screening significantly reduced mortality from prostate cancer but did not affect all-cause mortality.”

Why Doesn’t ScreeningWork Better?

• Co-morbidity (life expectancy)

• Lead time bias

• Over diagnosis bias (no progression over time)

Clinical Policy Options

1. No routine PSA screening

2. Screen all over 50 or 55• Biopsy only those with PSA> 10 • Active surveillance for those with high

levels of comorbidity (decreased 10 year life expectancy)

• Treatment only by high quality urologists

Clinical Policy Options (cont’)

3. Screen all those with high life expectancy

4. Leave it to the patient and the doctor to decide (USPSTF Level C)