Task Force Recommends Against Routine Prostate Cancer ScreeningMay 21, 2012
The United States Preventive Services Task Force (USPSTF) has issued new recommendations against prostate cancer screening. The USPSTF now recommends that regardless of age, men without symptoms should not routinely have the prostate-specific antigen (PSA) blood test to screen for prostate cancer.
The task force is an independent panel of experts authorized by Congress to make recommendations about specific preventive services for patients with no signs or symptoms. It released a draft of these recommendations in October, 2011.
In its final prostate screening recommendations, the task force concludes that, based on the current evidence, there is at least moderate certainty that the harms of PSA testing outweigh the benefits.
The USPSTF recommendation differs slightly from those of many other expert groups, including the American Cancer Society. The American Cancer Society recommends men make an informed decision about whether to be tested after learning about the potential risks and benefits of testing.
The USPSTF does, however, recognize that some men will continue to request PSA screening and some doctors will continue to offer it. The task force encourages patients and doctors to make an informed decision based on the patients’ preferences and an understanding of the possible risks and benefits.
Potential harms and benefits of screening
The task force last published recommendations on prostate cancer screening in 2008. At that time, it concluded that men over 75 should not be screened and that there was not enough evidence to recommend for or against screening in younger men.
The new USPSTF recommendations, published early online May 21, 2012 in Annals of Internal Medicine, are based largely on reviews of two large clinical trials of prostate cancer screening that have been published since 2008.
The main goal of prostate cancer screening is to reduce deaths due to prostate cancer. But the studies showed that the number of men who avoided dying of prostate cancer because of screening after 10 to 14 years was very small. In addition, the PSA test often produces false-positive results that lead to more testing, including biopsies, which can have their own side effects, according to the USPSTF.
Prostate cancer often grows so slowly that many men who have it detected during screening might never need treatment. Treatment itself can often have unpleasant, and sometimes long-lasting, side effects. One of the problems with prostate cancer screening is that it cannot determine which prostate cancers are aggressive and need treatment, and which are not likely to cause problems. As a result, most men diagnosed with prostate cancer also get active treatment.
The task force noted that nearly 90% of men with PSA-detected prostate cancer go on to have surgery, radiation, or hormone therapy. Up to 5 in 1,000 men will die within 1 month of surgery, and at least 20% and 30% of men getting surgery or radiation therapy will have serious long-term side effects such as urinary incontinence, erectile dysfunction, or bowel dysfunction. Hormone therapy is also associated with erectile dysfunction, breast enlargement, and hot flashes.
Prostate cancer is the most common cancer in American men (other than skin cancer) and occurs more often in African-American men. It strikes more than 240,000 men each year and kills about 28,000.
Not all experts agree
In an accompanying editorial, William J. Catalona, MD, Medical Director of the Urological Research Foundation and colleagues disagreed with the USPSTF recommendations. They believe that the task force underestimated the benefits and overestimated the harms of prostate cancer screening, and that the trials upon which the task force based its conclusions were flawed. Catalona and colleagues recommended that doctors review the evidence for themselves, and make individual decisions about prostate cancer screening based on the preferences of an informed patient.
In a second editorial, Otis W. Brawley, MD, MPH, Chief Medical Officer of the American Cancer Society, also stressed the need for informed decision-making, as the American Cancer Society and many other organizations recommend.
Brawley wrote that over-diagnosis of prostate cancer can make screening seem to save lives when it may not. Many men are diagnosed with prostate cancer that may never have progressed within their lifetime; yet because they were screened and treated, they think screening saved their lives.
Brawley wrote, “Americans have been taught for decades to fear all cancer and that the best way to deal with cancer is to find it early and treat it aggressively. As a result, many have a blind faith in early detection of cancer and subsequent aggressive medical intervention whenever cancer is found. There is little appreciation of the harms that screening and medical interventions can cause.”
The American Cancer Society recommends that men discuss the possible risks and benefits of prostate cancer screening with their doctor before deciding whether to be screened. The discussion about screening should take place at age 50 for men who are at average risk of prostate cancer and at age 45 for men who are at higher risk, including African-American men and men who have a father or brother diagnosed with prostate cancer.
Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement. Published early online May 21 in Annals of Internal Medicine. First author: Virginia A. Moyer, MD, PhD, Baylor College of Medicine, Houston, Texas.
Screening for Prostate Cancer: A Review of the Evidence for the U.S. Preventive Services Task Force. Published early online May 21 in Annals of Internal Medicine. First author: Roger Chou, MD, Oregon Health & Science University, Portland, Ore.
What the U.S. Preventive Services Task Force Missed in Its Prostate Cancer Screening Recommendation. Published early online May 21 in Annals of Internal Medicine. First author: William J. Catalona, Northwestern University, Chicago, Ill.
Prostate Cancer Screening: What We Know, Don’t Know, and Believe. Published early online May 21 in Annals of Internal Medicine. First author: Otis W. Brawley, MD, MPH, American Cancer Society, Atlanta, Ga.