Task force rethinks guidelines: recommends men age 55-69 resume prostate cancer screening, with physician input
A reversal of 2012 U.S. Preventative Services Task Force (USPSTF) recommendations— that had called for all men to forego prostate cancer screening— was released this week.
Two- tiered recommendations
USPSTF now suggests men age 55 to 69 should resume discussions of prostate cancer screening with their physician. Screening would include men who do not have any signs or symptoms of prostate cancer. USPSTF reversed its recommendations based on new research that demonstrated a negative impact of their 2012 advice against routine PSA blood testing.
The task force furthermore advises men who have reached age 70 should discontinue screening for prostate cancer, rather than age 75 as previously recommended. USPSTF cites “moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.”
According to USPSTF, revised recommendations apply to men in each age group, whether they are at an average risk for prostate cancer, and even men at increased risk, such as African Americans and men with a family history of prostate cancer. USPSTF states there are not enough data to make a different recommendation, even though decision models strongly suggest that African American men have more to gain by screening and may also benefit by starting earlier than the age of 55.
Prostate Cancer Foundation of Chicago (PCFC) champions early detection and concurs in large part with the direction of these recent recommendations. Yet, we support that men generally begin receiving annual screening at age 50, which is 5 years earlier than recommended by USPSTF. For men at increased risk for prostate cancer, we recommend screening beginning at age 40, or 15 years earlier than USPSTF advises.
Add DRE for greater detection power
Unlike USPSTF, PCFC also promotes prostate cancer screening that further includes digital rectal examination (DRE). DRE fell out of favor when many physicians stopped offering their patients routine screening. In combination with PSA, DRE can uncover abnormalities associated with prostate cancer, even with a normal PSA level.
New evidence of benefits for men age 55 to 69
The USPSTF had previously suggested that PSA testing could lead to unnecessary biopsies and treatment of insignificant cancers. Task force member Alex H. Krist, MD, MPH, in an interview stated, “There is new evidence to suggest that there is slightly more benefit to screening than we thought before in 2012. The important thing that we are trying to emphasize is that there is a real close balance between benefits and harms,” he said, but the balance has been tipped slightly toward benefit for the age group aged 55 to 69.”
Less screening led to higher grade tumors when detected
Several studies— and the outcry from many urologists and prostate cancer patients— lead USPSTF to reconsider discouraging men from receiving PSA screening. Quoting K. Fleshner in Nature Reviews Urology , “Since the 2012 recommendation, rates of PSA screening decreased by 3–10% in all age groups and across most geographical regions of the USA. Rates of prostate biopsy and prostate cancer incidence have declined in unison, with a shift towards tumours being of higher grade and stage upon detection.”
Results of the European Randomized Study of Screening for Prostate Cancer, demonstrated that slightly more men who are screened would not die from prostate cancer than was the case previously (in 2012). Also from the European trial, longer-term follow-up shows that three men out of 1000 will avoid advanced prostate cancer because of screening.
Genomic testing of tumors informs treatment decisions
A discussion of a possible limitation of prostate cancer screening points to the difficulty of knowing which cancers will be more likely to advance beyond the prostate. If a man is found to have a prostate tumor, genomic testing is now available for physicians to understand more about the aggressiveness of a patient’s cancer cells and help men make better prostate cancer treatment decisions.
Education is key
Like the USPSTF, PCFC advocates patient education and shared decision making between doctor and patient. Discussions of the pros and cons of screening, and available treatment options, will continue to be important for men to have with their family and their physician.
For more information on prostate cancer and screening, contact PCFC at 630-654-2515 or visit the PCFC website. Prostate Cancer Foundation of Chicago advances patient education, by offering free prostate cancer screening and hosting an Informational Patient Support Group.