Prostate Cancer Screening: Navigating the New Recommendations
"A clear look at the latest guidelines and how they impact your health decisions."
In April 2017, the US Preventive Services Task Force (USPSTF) released updated draft recommendations regarding prostate-specific antigen (PSA)-based prostate cancer screening. For men aged 55 to 69, a 'C' recommendation suggests individual decision-making due to the small potential benefit. For men 70 and older, a 'D' recommendation advises against screening. While some see this as an endorsement of screening, the reality is more complex.
The previous 2012 USPSTF recommendations discouraged PSA testing for all asymptomatic men, regardless of age, race, or family history, based on evidence suggesting that the harms of screening outweighed the benefits. At the time, screening was estimated to prevent 0 to 1 prostate cancer deaths per 1000 men over 10 years, while causing harms like false positives, biopsy complications, overdiagnosis, and overtreatment.
So, what's changed in the last five years? The USPSTF points to new evidence suggesting greater benefits and reduced harms, citing longer-term results from the European Randomized Study of Screening for Prostate Cancer, which demonstrated that fewer men were needed to be screened to prevent one prostate cancer death. The USPSTF also gave less weight to negative results from the U.S. Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial.
Understanding Overdiagnosis and the Role of Active Surveillance
A key concern with prostate cancer screening is overdiagnosis, where cancers are detected that would not have caused problems during a man's lifetime, leading to overtreatment with surgery or radiotherapy. The Prostate Cancer Intervention Versus Observation Trial (PIVOT) found no overall survival benefit for surgery versus watchful waiting in veterans with localized cancers diagnosed via PSA testing.
- Active Surveillance: Involves deferring immediate treatment and monitoring the cancer through regular PSA testing and biopsies.
- American Urological Association and National Comprehensive Cancer Network: Have endorsed active surveillance as a management strategy.
Making Informed Decisions: A Collaborative Approach
Prostate cancer screening decisions remain complex. Although the evidence suggests a better balance between benefits and harms, the absolute benefit remains small, and screening can still lead to harm. The USPSTF emphasizes informing men about the implications of screening and enabling them to make decisions based on their values and preferences through shared decision-making.
To facilitate shared decision-making, healthcare providers should use prostate cancer screening decision aids, considering the complexities and time constraints involved. A public awareness campaign is needed to direct men toward high-quality, culturally appropriate information and tools, empowering them to proactively engage with their providers.
The USPSTF's adjusted recommendation, acknowledging that screening is a preference-sensitive decision, is a step in the right direction. However, it's crucial to avoid viewing the change from a 'D' to a 'C' recommendation as an endorsement of routine screening. Instead, providers and patients must engage in shared decision-making to ensure that men's values and preferences are integrated into screening and treatment decisions.