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US Task Force Releases Recommendations for Prostate Cancer Screening

NEW YORK (360Dx) – The US Preventive Services Task Force said today that men aged 55 to 59 should decide with their clinicians whether to pursue prostate specific antigen-based cancer screening.

The decision to undergo periodic PSA screening should be an individual one and should include discussion of the potential benefits and harms of screening with their clinicians, the USPSTF said in a recommendation statement published in JAMA. The USPSTF further recommended against PSA-based screening for prostate cancer in men 70 years and older.

The update and its recommendations are supported by an evidence report and systematic review, and it aligns the USPSTF with American Cancer Society and the American Urological Association recommendations, the USPSTF said. However, the new recommendation alters its previous stance published in 2012 when the USPSTF recommended against PSA-based screening for prostate cancer in all age groups, saying the benefits of screening did not outweigh the risks.

In April 2017, USPSTF announced that it had created a draft guideline, a precursor to the final recommendations, with changes from the 2012 guidance.

The change from the 2012 guideline, resulting in a new C recommendation for men aged 55 to 69 years compared with a prior D recommendation for all ages, seeks to address confusion among many men about whether they should get screened for prostate cancer, a slow-growing disease that typically takes years before it becomes life-threatening.

According to the USPSTF, screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. "However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction," the USPSTF said in JAMA.

In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms based on several criteria, it said. These include family history, race/ethnicity, comorbid medical conditions, patient values about the benefits and harms of screening and treatment-specific outcomes, and other health needs, it noted.

In a review for USPSTF also published today in JAMA, researchers at the University of California, Davis, reported on their systematic evaluation of evidence about PSA screening for prostate cancer, treatments for localized prostate cancer, and pre-biopsy risk calculators. To inform the USPSTF, they searched a range of sources, including PubMed, Embase, Web of Science, and Cochrane Registries from July 1, 2011, through July 15, 2017.

The authors included randomized clinical trials and cohort studies of active localized cancer treatments versus conservative approaches, such as active surveillance and watchful waiting. They also included reports of randomized clinical trials of screening; cohort studies reporting harms; and external validations of pre-biopsy risk calculators to identify aggressive cancers.

They concluded that PSA screening could reduce prostate cancer mortality risk, but that it is associated with false-positive results, biopsy complications, and overdiagnosis. They estimated that overdiagnosis occurred in 20.7 percent to 50.4 percent of screen-detected cancers. "Compared with conservative approaches, active treatments for screen-detected prostate cancer have unclear effects on long-term survival, but are associated with sexual and urinary difficulties," the authors said.

Richard Hoffman, a professor of internal medicine at the University of Iowa Carver College of Medicine, writing in an opinion paper published online today in JAMA Internal Medicine, said that the new USPSTF prostate cancer screening recommendation appear to have a large influence on practice patterns.

In the year following the 2011 release of a draft recommendation against any screening, he said, the number of men diagnosed with prostate cancer decreased by more than 33,000. Prostate cancer screening rates also subsequently decreased among all age groups by 2013. "The new recommendation may well be associated with a resurgence in prostate cancer screening and increased numbers of prostate cancer cases diagnosed, especially if the new guidelines are misunderstood to be endorsing screening rather than offering a more nuanced message about decision making," Hoffman said.

In the US, the lifetime risk of being diagnosed with prostate cancer is about 13 percent, and the lifetime risk of dying of prostate cancer is 2.5 percent, according to USPSTF. The median age of death from prostate cancer is 80 years. African-American men and men with a family history of prostate cancer have an increased risk of prostate cancer compared with other men, according to the USPSTF.

Peter Carroll, a researcher at the University of California, San Francisco, said in a separate opinion paper published in JAMA Surgery that the updated recommendations are a step in the right direction. "The USPSTF … recommendation for prostate cancer screening has restarted a national discussion on prostate cancer early detection," he said, adding that USPSTF "deserves credit for this more balanced, fairer approach," and that the message because of the update is for smarter screening that preserves benefits and reduces harms.