Draft USPSTF Guidelines Forecast a New Approach to Routine PSA Screening

Eric A. Klein, MD

Eric A. Klein, MD

The US Preventive Services Task Force may move away from its long-standing opposition to routine PSA screening for prostate cancer in some men.

In a draft guideline released today, the task force takes the position that for men aged 55 to 69, the decision to undergo screening “is an individual one.” The task force said physicians should inform their patients of the risks and benefits associated with screening, and they should decide on the best course of action together.

“Screening offers a small potential benefit of reducing the chance of dying of prostate cancer. However, many men will experience potential harms of screening, including false-positive results that require additional workup, overdiagnosis and overtreatment, and treatment complications such as incontinence and impotence,” the task force said in its recommendation. “The USPSTF recommends individualized decision-making about screening for prostate cancer after discussion with a clinician, so that each man has an opportunity to understand the potential benefits and harms of screening and to incorporate his values and preferences into his decision.”

The draft recommendation also applies to adult men who have not been previously diagnosed with prostate cancer and have no signs or symptoms of the disease, men at average risk, and men who are at increased risk for prostate cancer, including African-American men and men with a family history of prostate cancer.

USPSTF still recommends against screening for men aged 70 and older.

“Prostate cancer is one of the most common cancers to affect men, and the decision about whether to begin screening using PSA-based testing is complex,” Alex H. Krist, MD, associate professor of family medicine and population health at Virginia Commonwealth University and a member of the task force, said in a press release. “In the end, men who are considering screening deserve to be aware of what the science says, so they can make the best choice for themselves, together with their doctor.”

The guideline is not final and remains open for public comment until May 8.

The task force based the change on new evidence showing the benefits of screening, including reduced risk for disease-specific death and risk for metastatic disease. However, the task force still takes the position that screening often results in a false positive, which can lead to repeated blood tests and biopsies. Worse, patients may undergo unnecessary treatment, which can cause adverse events (AEs) such as impotence and incontinence. USPSTF said patients are more likely to experience AEs than receive a benefit.

“[I’m] pleased that the new recommendation is evidence based—first from the ERSPC [European Randomized Study of Screening for Prostate Cancer], a study that shows that screened men are about 30% less likely to die of prostate cancer and 35% less likely to get metastatic disease, and data showing the use of active surveillance is growing,” Eric A. Klein, MD, chair of the Glickman Urological & Kidney Institute at Cleveland Clinic, said in an interview with Oncology Nursing News.

“It has always been my view that the decision to be screened and treated for prostate cancer, including the potential side effects of treatment, should be in the hands of individual patients and not be decided by a government agency,” added Klein. “The newer recommendation should empower men to be proactive about learning about the benefits and risks of screening and not avoid asking about it because their personal physician is not a believer in screening and never even broaches the subject; men should ask for the facts and not be shy about asking to have a PSA ordered if they feel it’s in their interest to do so.”

In 2012, the USPSTF recommended against all routine testing and the American Urological Association (AUA) strongly protested the move at the time. The AUA was more supportive of today’s move.

“The AUA commends the USPSTF for its decision to upgrade its recommendation for prostate cancer screening,” AUA President Richard K. Babayan, MD, said in a statement. “The draft recommendations released today are thoughtful and reasonable, and are in direct alignment with the AUA’s clinical practice guideline and guidelines from most other major physician groups.”

Though the draft recommendation applies to African-American men, who are at increased risk for developing and dying from prostate cancer, task force chair Kirsten Bibbins-Domingo, MD, PhD, said this high-risk group has been woefully understudied.

“We remain particularly concerned about the striking absence of evidence to guide these high-risk men specifically as they make decisions about screening,” she said. “Additional research on prostate cancer in African American men should be a national priority.”

References

• U.S. Preventive Services Task Force seeks comments on draft recommendation statement on screening for prostate cancer [news release]. U.S. Preventative Services Task Force. April 11, 2017. Available at: http://www.prnewswire.com/news-releases/us-preventive-services-task-force-seeks-comments-on-draft-recommendation-statement-on-screening-for-prostate-cancer-300437870.html.
• AUA responds to USPSTF draft recommendations on screening for prostate cancer [news release]. The American Urological Society. April 11, 2017. Available at: https://www.auanet.org/press-media/press_releases/article.cfm?articleNo=501.