The Ethical Dilemma Surrounding Prostate Specific Antigen (PSA) Screening Zaina P Qureshi * , Charles Bennett, Terhi Hermanson, Ronnie Horner, Rifat Haider, Minjee Lee and Richard J Ablin University of South Carolina, Columbia, South Carolina, USA * Corresponding author: Zaina Qureshi, University of South Carolina, Columbia, South Carolina, USA, Tel: 8037778139; E-mail: qureshiz@mailbox.sc.edu Rec date: Nov 20, 2014, Acc date: Jan 07, 2015, Pub date: Jan 15, 2015 Copyright: © 2015 Qureshi Z, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Abstract The Food and Drug Administration approved testing for prostate cancer screening in 1994. Today over four decades have passed since the Prostate-Specific Antigen (PSA) was first discovered. Yet enormous uncertainty governs the effectiveness of PSA testing as well as the appropriate strategy to best detect early prostate cancer. Many groups including the American Cancer Society (ACS), the National Comprehensive Cancer Network (NCCN), the American Urological Association (AUA) and the US Preventative Services Task Force (USPSTF), have issued a series of clinical guidelines for prostate cancer screening with inconsistent recommendations. Research shows that prostate cancer screening with PSA resulting in a false-positive screen occurs among 80 percent of men, while 20 percent of men have false-negative results. Recently changes to existing recommendations were suggested by the USPSTF due to concerns of negative effects of PSA testing on patient outcomes. While the evidence underlying prostate cancer screening recommendations is continuously in flux, it is important to understand implications of the debate for clinicians and men. In this paper we examine ensuing ethical considerations of PSA screening for prostate cancer. Keywords: Prostate cancer; Prostate specific antigen; Multiparametric MRI; Ethics Background The American Cancer Society (ACS) estimates a total of 1,665,540 new cancer cases and 585,720 cancer deaths to occur in the United States in 2014 [1]. An estimated 233,000 new cases of prostate cancer are expected to be diagnosed in 2014 and 29,480 are expected to die of prostate cancer [2]. Excluding skin cancer, prostate cancer is the most commonly diagnosed cancer among men in the United States and the second most common cause of cancer death among men. About 1 in 6 men in the United States will be diagnosed with prostate cancer during their lifetime and 1 in 36 will eventually die from prostate cancer [3]. Despite the important burden of prostate cancer cases and deaths, and extensive research on its causes, prevention, early detection, and treatment, uncertainties abound with respect to prostate cancer prevention, screening, and treatment. Current strategies for reducing the burden of prostate cancer are primarily aimed at early detection of clinically significant cancers and determining which prostate cancers are likely to be clinically insignificant. This is substantiated by scientific literature that suggests that early detection can play a vital role in detecting clinically important prostate cancers, and distinguish these cancers from those that are unlikely to be clinically relevant during ones life [4]. Despite the large expanse of medical literature on early detection, differences of opinion abound on frequency of screening, appropriate age to initiate screening (if ever), interpretation of Prostate-Specific Antigen (PSA) results, and appropriate follow-up and treatment of men with proven prostate cancer. The enduring controversy is whether PSA screening should be recommended because of psychological and medical costs associated with PSA testing [5-7]. There are many persons and organizations who do not support population-based screening with PSA testing, based on concerns that present screening methods increase morbidity without affecting all-cause mortality [8]. Prostate cancer screening tools Most clinically relevant as well as clinically insignificant prostate cancers are diagnosed through PSA screening, while a minority of new prostate cancers are diagnosed by Digital Rectal Examination (DRE) [9]. Early prostate cancer usually has no symptoms. With more advanced prostate cancers, men may experience weak or interrupted urine flow; inability to urinate or difficulty starting or stopping the urine flow; the need to urinate frequently, especially at night; blood in the urine; or pain or burning with urination. However, these symptoms occur frequently as a result of non-cancerous conditions, including prostate enlargement or prostate infection. Advanced prostate cancer commonly spreads to the bones, which can cause pain in the hips, spine, ribs, or other areas. It has been suggested that PSA screening can detect prostate cancer years earlier than it would be detected by a DRE or development of symptoms, although the overwhelming majority of these cancers are not likely to be clinically significant [10]. Potential errors in diagnosis can be attributed to the many limitations of PSA screening. Although there is no absolute cutoff between a normal and an abnormal PSA level, prostate cancer screening programs initially considered >4 ng/mL as a positive PSA screening test. Many men who do not have prostate cancer will screen positive and require a biopsy for diagnosis (potentially due to benign prostate hyperplasia, prostatitis, urinary tract infections or prostate biopsies/surgery), and some men with prostate cancer many not have elevated PSA levels. Most importantly, PSA testing does not differentiate between low and high risk cancers. Because many prostate cancers grow so slowly that they never threaten a patient’s life, overtreatment of prostate cancer with radical prostatectomy or radiation therapy is common. This is a particularly important issue since treatment for prostate cancer with radiation or surgery is associated with significant side effects. Clinical Research & Bioethics Qureshi et al., J Clinic Res Bioeth 2015, 6:1 http://dx.doi.org/10.4172/2155-9627.1000206 Review Article Open Access J Clinic Res Bioeth ISSN:2155-9627 JCRB, an open access journal Volume 6 • Issue 1 • 1000206