Prostate cancer remains the in men in the U.S., and there has been a worrisome trend of rising metastatic disease at diagnosis. These facts make it increasingly important that the urological community and the patients we serve turn our attention to ways to overcome these challenges.
The Role of Screening
As a urologist practicing in Shreveport, a majority-minority city in Louisiana -- the state with the of prostate cancer -- I am well aware that Black men in the U.S. have the highest mortality rate for prostate cancer and are twice as likely to die from it as white men. Consequently, Black men are more likely to be saved by screening.
Prostate-specific antigen (PSA) screening may be more controversial today than decades ago, as more about the balance of benefits versus potential harms of unnecessary treatment. However, there is one aspect of this disease on which the entire healthcare community agrees: for both the diagnosis and treatment of prostate cancer, patient-physician shared decision-making should be optimized. Providers must have the ability to counsel patients on evidence-based best practices, taking into account the individual's risk factors and personal preferences.
Unfortunately, policy changes over the past few years have made access to screening increasingly challenging. This is an issue that must be addressed at a Congressional level.
Consider a on PSA screening in men ages 40 and older released at the 2021 Genitourinary Cancers Symposium. The data suggest that the 2012 decision by the U.S. Preventive Services Task Force (USPSTF) to de-prioritize PSA testing has resulted in a higher proportion of men diagnosed with metastatic prostate cancer in later stages than before the USPSTF policy. This decision was faulty from the beginning, as it was loosely based on an erroneous interpretation of previous data and undermines the benefits of PSA tests.
There is a between PSA screening and diagnosing prostate cancer at an earlier stage. Despite multiple studies identifying this upward shift of prostate cancer metastatic at diagnosis, the USPSTF still devalues PSA testing by giving it a , suggesting that the balance of benefits and harms is close and that the extent of the net benefit is small. In contrast, a rating of a B or higher would carry the recommendation to providers to offer or provide the service. The USPSTF's current C rating is inappropriate because it not only negates a physician's expertise and knowledge of a patient's health history, but it also undermines recent breakthroughs in molecular and genomic testing that facilitate personalized precision healthcare delivery. Furthermore, as many insurers and providers use USPSTF ratings as one factor in planning treatment, men cannot be confident their insurance company will cover the cost of their PSA test.
This unacceptable circumstance diminishes the value of adequate access to PSA screening at a time when the number of deaths due to prostate cancer has been increasing. Many lives may not have been lost had people's cancer been detected earlier.
Removing Barriers to Screening
The current rating highlights the essential role government regulators must play in removing barriers to screenings for those at high risk of developing prostate cancer, including Black men; those with a family history of prostate cancer; and professionals and servicemen who may have suffered exposure to cancer-causing toxins.
So, what can be done? Congress -- though often ineffective at passing meaningful piecemeal healthcare legislation -- can begin by reforming the process USPSTF uses to issue recommendations and guidance. Congress should hold this powerful, yet unelected agency to the same standards as other bureaus. The USPSTF Transparency and Accountability Act, introduced in every Congress since 2015, has sought to improve the accountability and processes of this unelected body.
Waiving cost-sharing -- including deductibles, copayments, and coinsurances -- for at-risk patients will help more men, including those affected by regional, economic, and racial disparities, to secure earlier diagnoses and better treatment options. Some states are introducing legislation to require insurers to cover prostate cancer screening, as state action has become increasingly commonplace due to congressional inaction on various issues. But the problem of prostate cancer in the U.S. is bigger than any one state's legislature, and it has gotten worse, especially regarding prevention.
If elected officials in Congress are committed to reducing racial disparities in prostate cancer deaths, expanding access to healthcare, and protecting generations of American men, re-introducing and passing the USPSTF Transparency and Accountability Act is one of the simplest and most impactful actions they can take. As public policy catches up to the medical realities of prostate cancer, the work to educate and update primary care providers on the importance of PSA screening will remain essential.
Jonathan Henderson, MD, is president of the Large Urology Group Practice Association (LUGPA).