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To PSA, or Not to PSA?


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To PSA, or Not to PSA?

By Jock Hoffman, CRICO

Related to: Clinical Guidelines, Diagnosis, Primary Care

That question has long suffered the slings and arrows of both the medical journals and the lay press. Clinical researchers and public health authorities puzzle about the risks/benefits of routine prostate-specific antigen (PSA) testing and advise caution towards aggressive prostate cancer treatment. Meanwhile, a long line of male celebrities espouse the life-saving merits of prostate cancer screening and treatment. Patients receive mixed messages and their doctors are left to sort it out.

From a medical malpractice perspective, however, the merits of PSA testing are less relevant than the processes associated with routine screening. From 2004–2008, 21 malpractice claims and suits alleging a failure to timely diagnose prostate cancer were asserted against (25) CRICO-insured clinicians. Those cases, which represent more than $15 million in incurred losses, most commonly involve communication or documentation breakdowns in three diagnostic steps: 1) discussions about screening; 2) tracking test results; and 3) following up those results with appropriate referrals or treatment. More than three quarters of the physicians defendants were primary care providers (PCPs).

To avoid this sea of troubles, PCPs are best protected by a proactive approach. This begins with a brief (documented) discussion with risk-stratified patients about prostate cancer screening, particularly PSA testing. Patients who understand the a) limitations (and risks) of testing—including false positive and false negative results, b) the requirement for periodic retesting, and c) the ramifications of a worrisome finding, are able to make an informed decision.

Recommendations for the specifics of the patient discussion and testing intervals vary, but the need for vigilance is universal. For patients who decline PSA testing, the topic should be revisited periodically (i.e., “no” is not necessarily “never”). Once an informed patient has agreed to PSA testing, a system to track the results and trigger subsequent testing is essential. And, when patients present with non-cancerous prostate ailments (e.g., benign prostatic hyperplasia), the treating physician has to keep sight of the cancer screening regimen and beware of attributing all symptoms to the acute condition.

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April 1, 2009
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