PSA Testing and Reduction of Mortality Rates

Effectiveness of Mass PSA Testing in Reducing Mortality Rates

Prostate cancer screening is considered as one of the crucial steps towards dealing with the problem of prostate cancer among various patient population. Healthcare providers consider screening as a crucial issue towards improving the health and well-being of patients. In light of the significance of prostate cancer screening in health promotion, several screening tools have been developed and are utilized in the clinical setting such as digital rectal exam (DRE) and prostate-specific antigen (PSA) testing. PSA testing has received considerable attention in the recent past, particularly in relation to its impact on mortality rates. PSA testing/screening for prostate cancer remains a controversial issue in the modern healthcare setting given the variance in evidence on its impact on mortality rates. This paper examines whether PSA testing reduces morality rates based on research evidence or evidence-based practice. The analysis is carried out based on evidence-based nursing practice, which helps in solving problems through four major steps. These steps are identification of the controversial problem, search for relevant research studies, evaluation of research evidence, and most suitable intervention.
Controversial Issue/Problem
The controversial issue that will be the subject of this paper is PSA testing and mortality rates in today’s clinical setting. According to Vis (2002), PSA-based testing or screening for prostate cancer is one of the major controversial issues in the modern healthcare sector. PSA testing was established following the increased availability of valid screening tests and the likelihood of success of curative treatment alternatives for prostate cancer. Healthcare providers and authorities in the United States have continued to advocate for the use of PSA testing for prostate cancer given these factors.
Prostate cancer is one of the most common and frequent causes of cancer-related death among men aged 65 years or older. It is reported that prostate cancer is the third leading cause of cancer-related death among American men following lung cancer and colorectal cancer. Lung cancer accounts for 44.7% of cancer-related deaths while colorectal cancer accounts for 21.2% and prostate cancer accounts for 20% (Cancer Statistics Center, 2017). The lifetime risk for American men to develop prostate cancer is 16% whereas the risk of dying from this condition is only 2.9% (American Cancer Society, 2017). In this regard, even though prostate cancer is a major health problem, most men diagnosed with the condition do not die from it. However, mortality rates associated with prostate cancer has received significant attention in the health sector in the recent past. Healthcare authorities and professionals consider prostate cancer screening as a crucial element towards lessening the incidence rate, prevalence rate, and mortality rates. Consequently, various tools have been developed to help in screening for prostate cancer including prostate-specific antigen (PSA) testing. While PSA testing is regarded as an important tool for prostate cancer screening, it has remained a controversial issue, particularly in relation to its impact on mortality rates and will be the subject of this paper.
Literature Review
Given the controversy relating to PSA testing and mortality rates, the issue has been the subject of numerous studies that seek to enhance understanding and improvement in clinical practice. Vis (2000) conducted a study to examine whether PSA testing reduce prostate cancer mortality in light of its increased use to screen for prostate cancer. Additionally, the researcher conducted the study on the premise that PSA testing remains a controversial issue in prostate cancer diagnosis and treatment. The study found that PSA testing does not reduce mortality rates contrary to widespread beliefs and assertions. The researcher found that decline in prostate mortality rates even in countries that utilize PSA testing is not attributable to these tests, but brought by the increased use of curative treatment options. For instance, Canada and European countries that discourage the application of PSA testing have experienced reduction in mortality rates because of the increased use of curative treatment alternatives (Vis, 2000). These alternatives include diet and lifestyle changes, enhancement in environmental conditions, and early application of luteinizing hormone-release hormone (LHRH) agonists. The declined mortality rates started to occur even before the advent of PSA testing.
Howrey et al. (2013) investigated the effect of PSA testing on prostate cancer mortality rates in the United States. The study examined the issue through a comparison of PSA testing rates in counties in the U.S. to prostate biopsies rates and newly-treated prostate cancer and deaths associated with this health condition. Based on the findings of the research, PSA testing is linked to moderate decrease in prostate cancer mortality. The researchers also found that PSA testing contributes to significant increases in the number of men over-diagnosed and over-treated for this condition.
According to a study by Mitka (2012), mass PSA testing does not result in decrease in the risk of dying from prostate cancer. The research was conducted on an annual population-wide screening for prostate cancer through the use of serum PSA screening and found that the testing does not lessen the risk of prostate cancer death. Similarly, Mulhem, Fulbright & Duncan (2015) contend that PSA testing does not lessen mortality rates. Through a study that evaluates PSA testing, Mulhem, Fulbright & Duncan (2015) found that PSA testing has low specificity and sensitivity for prostate cancer and there is lack of evidence for determining the required threshold that necessitates prostate biopsy. Even though prostate cancer screening increases diagnosis of prostate cancer, PSA testing is associated with some adverse effects including prostate biopsy, overdiagnosis, and overtreatment.
Wilt et al (2014) state that there is minimal or no benefit of PSA testing among older men or those with limited life expectancy. Even though several prospective trials, simulation models, observational studies, and retrospective analyses have been carried out, PSA testing has been found to be of limited or no benefit, especially with regards to mortality rates. The researchers state that there is an agreement between the relevant stakeholders that actual harms are linked to downstream clinical actions and have minimal to no benefit on prostate cancer in terms of mortality rates. In an earlier study, Slatkoff et al. (2011) found that PSA testing is beneficial in some situations and not helpful in others. Based on their study, Slatkoff et al (2011) contend that PSA testing is slightly beneficial to men below the age of 75 years and without cancer or cardiovascular risk factors. However, the slight benefit is inadequate to conclude that PSA testing is helpful in prostate cancer diagnosis and treatment processes. The researchers also argue that PSA testing has significant limitations and possible harmful effects, which largely outweigh its benefits. In this case, PSA testing does not reduce mortality rates because 75% of positive tests are false positives and are linked to psychological damages in some men that could last up to a year after the screening. Some factors that contribute to false positive PSA test results include elevated PSA readings, pre-existing conditions like urinary tract infections, and ejaculation 24 hours before the test. The psychological damages of false positive PSA test results include increased anxiety and stress.
On the other hand, some studies indicate that PSA testing is beneficial and can help lessen prostate cancer deaths. Nelson (2014) who reviewed the impact of PSA testing on mortality rates argued that routine PSA testing for prostate cancer helps in saving lives. Based on updated results from the European Randomized study of Screening for Prostate Cancer (ERSPC), PSA testing has been found to have significant lessening in prostate cancer mortality rates. However, the study does not recommend PSA testing on the premise that its associated with overdiagnosis and overtreatment. In concurrence, Begley (2017) argues that an evaluation of two influential studies on prostrate cancer screening shows that PSA testing lessens death from this condition. One of the influential studies was carried out by the National Cancer Institute i.e. Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening and focused on determining the impact of screening on cancer-related mortality. The second influential study was conducted the American College of Physicians focused on examining the risks and benefits of PSA testing. Begley (2017) postulates that current suggestions against regular PSA screening could be directing men away from a vital lifesaving process. Therefore, the researcher seemingly argues that PSA testing reduces prostate cancer mortality rates.
Analysis of Research Evidence
As shown in the review of existing literature on this issue, there are two contradictory positions or arguments. First, there are arguments that PSA testing reduces mortality rates associated with prostate cancer while there are also arguments that PSA testing does not reduce prostate cancer mortality. The argument that prostate cancer reduces prostate cancer mortality is based on review of existing studies and population-based screening programs that have seemingly demonstrated a decline in mortality rates through regular PSA testing. Based on these reviews and programs any kind of reduction in mortality rates including a 20% reduction is significant to conclude that PSA testing saves lives (Begley, 2017). However, these studies demonstrate that PSA testing is associated with adverse impacts including overdiagnosis and overtreatment of prostate cancer. The overdiagnosis and overtreatment are considered as some of the risk factors that contribute to high prostate cancer mortality.
The suggestion that PSA testing reduces prostate cancer mortality is erroneous because its based on completely unverifiable methodology as shown in the analysis of the two influential studies by Begley (2017). According to Begley (2017), the review of two influential studies that led to the conclusion that PSA testing lessens prostate cancer is based on completely unverifiable methodology and a shaky foundation. As stated by some cancer screening and statistics experts, there is no sufficient evidence to support the argument that PSA testing reduces mortality rates (Mitka, 2012; Mulhem, Fulbright & Duncan, 2015; Begley, 2017).
Additionally, there is lack of clear data to demonstrate whether PSA testing is linked to any mortality benefit (Nelson, 2014). The lack of clear data continues to exist at a time when PSA testing is not designed for regular screening and cannot detect prostate cancer (Nelson, 2014). The failure of PSA testing to reduce prostate cancer mortality rates is also attributable to the fact that this screening technique cannot distinguish between rapidly growing and potentially fatal prostate cancer and one that is growing gradually and will not result in fatality. This implies that PSA testing cannot be utilized as a tool for reduction of mortality rates among patients diagnosed with prostate cancer.
The argument that PSA testing does not reduce mortality rates is well supported in existing literature. One of the critical steps towards lessening prostate cancer mortality is conducting regular/routine screenings using techniques or tools like digital rectal exam. In this case, PSA testing does not help achieve this since its not designed for routine screenings for prostate cancer. Secondly, it is quite evident that PSA testing is associated with some unnecessary procedures that enhances mortality risk such as overdiagnosis and overtreatment. Additionally, PSA testing is associated with some harms like anxiety and side effects from prostate biopsy such as infections, difficulties in urinating, rectal bleeding, and blood in the urine (Mulhem, Fulbright & Duncan, 2015). Given these factors, there is no healthcare organization that recommends routine PSA testing (Nelson, 2014). Studies suggesting that PSA testing reduces mortality rates do not recommend it because of these adverse effects that could serve as risk factors for enhancing prostate cancer mortality. Therefore, existing research evidence demonstrates that PSA testing does not reduce prostate cancer mortality rates. Mass PSA testing is a population-wide screening campaign that is carried out to help in diagnosis and treatment of the condition among the targeted population.
Most Suitable Alternative to PSA Testing
The review of existing research evidence has demonstrated that PSA testing does not lessen prostate cancer mortality. In this regard, there is need to identify a suitable intervention or alternative to PSA testing for lessening prostate cancer mortality rates. The alternative should be based on evidence-based nursing, which is the process through which physicians make clinical decisions based on the best available research evidence. One of the recommended alternatives to PSA testing to help reduce prostate cancer mortality is informed decision-making at the individual level. Since no healthcare organization or authority recommends PSA testing, informed decision-making at the individual level before testing is considered as a suitable approach to address the problem while avoiding the harmful/adverse effects of PSA testing (Mulhem, Fulbright & Duncan, 2015).
While this alternative could be a suitable option to help resolve the problem, it’s associated with some risks that affect its effectiveness in lessening mortality rates associated with prostate cancer. Informed decision-making at individual level before testing has been found to carry significant burden that could in turn enhance mortality rates (Gulati, Gore & Etzioni, 2013). The recommendation of informed decision-making at an individual level is attributable to the fact that PSA testing is listed among the Choosing Wisely tests that physicians and patients should question. However, the shared-decision making approach through this strategy is difficult to achieve in a short office visit, which makes it difficult to implement.
Given the drawbacks of this informed decision-making approach and existing clinical expertise, the most suitable evidence-based practice for addressing this problem is personalized strategies for PSA testing (Gulati, Gore & Etzioni, 2013). This is a suitable alternative or intervention to address the problem of high prostate cancer mortality rates since it reduces the adverse effects/harms of PSA testing while preserving its benefits. The personalized PSA testing approach should be utilized instead of the aggressive screening approaches that have been found to generate unnecessary biopsies, diagnoses and treatments despite lessening mortality.
The personalized PSA testing approach entails less frequent screening and more conventional criteria for biopsy referral in older men (Gulati, Gore & Etzioni, 2013). This approach has been found to have significant improvements in the harm-benefit tradeoff of PSA testing. In this case, personalized PSA testing helps to preserve a significant portion of the survival effect and substantially reduce the adverse impacts or harms of screening in comparison to the reference strategy. The consideration of personalized PSA testing as a means of lessening prostate cancer mortality is attributable to the fact that this approach acts as the foundation for smart screening for prostate cancer.
Existing research evidence has supported the case for using personalized PSA testing as an approach towards enhancing PSA screening and lessening prostate cancer mortality. According to Gulati, Gore & Etzioni (2013), personalized PSA testing should incorporate an inter-screening interval that is expanded in men with low PSA. This will help in generating an individualized prediction of prostate cancer risk depending on individual factors like PSA, family history, age, and race. Helfand (2013) support this strategy on the premise that it will help lessen unnecessary prostate biopsies and contribute to reduced prostate cancer mortality. Personalized PSA testing helps in avoiding the adverse effects of general PSA screening through identifying genetic variants that contribute to the likelihood of diagnostic bias. This approach corrects the impacts of PSA testing on these variants, which in turn prevents overdiagnosis and overtreatment brought by PSA testing. In this case, individualized PSA testing incorporates genetic information that helps address the individual risk factors that could contribute to high prostate cancer mortality rates.
In conclusion, one of the most controversial issues or problems in public health policy and healthcare practice is prostate cancer screening. The controversy in prostate cancer screening is associated with PSA testing and mortality rates. There are concerns in public health on whether prostate-specific antigen (PSA) testing reduces mortality rates. Some studies have argued that PSA testing significantly reduces mortality rates while others have found that PSA testing does not reduce prostate cancer mortality. However, a review of existing research evidence demonstrates that PSA testing does not reduce mortality rates and is associated with overdiagnosis and overtreatment. As a result, the most suitable intervention to address this problem is personalized PSA testing approach, which incorporates the consideration of individual risk factors during screening.



References
American Cancer Society, Inc. (2017). Key Statistics for Prostate Cancer. Retrieved October 31, 2017, from https://www.cancer.org/cancer/prostate-cancer/about/key-statistics.html
Begley, S. (2017, September 5). Do Prostate Cancer Screenings Significantly Reduce Deaths? Retrieved October 31, 2017, from https://www.scientificamerican.com/article/do-prostate-cancer-screenings-significantly-reduce-deaths/
Cancer Statistics Center. (2017). 2017 Estimates. Retrieved November 3, 2017, from https://cancerstatisticscenter.cancer.org/#!/
Carter et al. (2011). Recommended Prostate-specific Antigen Testing Intervals for the Detection of Curable Prostate Cancer. The Journal of the American Medical Association, 277(18), 1456-1460.
Gulati, R., Gore, J.L. & Etzioni, R. (2013, February 5). Comparative Effectiveness of Alternative PSA-based Prostate Cancer Screening Strategies. Annals of Internal Medicine, 158(3), 145-153.
Helfand et al. (2013, May). Personalized PSA Testing Using Genetic Variants May Reduce Unnecessary Prostate Biopsies. Journal of Urology, 189(5), 1697-1701.
Howrey et al. (2013, January). The Impact of PSA Screening on Prostate Cancer Mortality and Overdiagnosis of Prostate Cancer in the United States. The Journal of Gerontology, Series A: Biological Sciences and Medical Sciences, 68(1), 56-61.
Mitka, M. (2012, January 6). Study: Mass PSA Screening Does Not Reduce Risk of Dying from Prostate Cancer. Retrieved October 31, 2017, from https://newsatjama.jama.com/2012/01/06/study-mass-psa-screening-does-not-reduce-risk-of-dying-from-prostate-cancer/
Mulhem, E., Fulbright, N. & Duncan, N. (2015, October 15). Prostate Cancer Screening. American Family Physician, 92(8), 683-688. Retrieved from http://www.aafp.org/afp/2015/1015/p683.html
Nelson, R. (2014, August 6). PSA Screening Does Reduce Deaths, but is Not Recommended. Retrieved October 31, 2017, from https://www.medscape.com/viewarticle/829507
Slatkoff et al. (2011, June). PSA Testing: When It’s Useful, When It’s Not. The Journal of Family Practice, 60(6), 357-360. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3183963/
Vis, A.N. (2002, March 5). Does PSA Screening Reduce Prostate Cancer Mortality? Canadian Medical Association Journal, 166(5), 600-601. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC99402/
Wilt et al. (2014, March 1). Prostate-Specific Antigen Screening in Prostate Cancer: Perspectives on the Evidence. Journal of the National Cancer Institute, 106(3). Retrieved from https://academic.oup.com/jnci/article/106/3/dju010/1745803/Prostate-Specific-Antigen-Screening-in-Prostate