April 12, 2017

New prostate cancer screening guidelines: What you need to know

Daily Briefing

    Read Advisory Board's take on this story.

    The U.S. Preventive Services Task Force (USPSTF) on Tuesday released a draft statement that relaxed its 2012 recommendation against routine prostate-specific antigen (PSA) testing for prostate cancer to instead say that men ages 55 to 69 and their physicians should decide whether the men should receive the tests.

    USPSTF in its previous guidance recommended against routine PSA tests because of evidence suggesting the potential harms associated with the test outweighed the potential benefits. However, urologists and prostate cancer patients pushed back on the guidance, touting the benefits of PSA screening. According to the Washington Post's "To Your Health," the American Urological Association (AUA) had denounced the 2012 recommendations as a "disservice" to men.

    Nearly 180,000 U.S. men are diagnosed with prostate cancer annually and at least 26,000 die from the condition, according to NPR's "Shots."

    USPSTF revises earlier recommendations based on new research

    USPSTF in the draft statement replaced the "D" grade it gave for PSA testing in the 2012 guidelines for men ages 55 to 69 with a "C" grade, saying men ages 55 to 69 should consult with their physicians to decide on an individual basis whether the men should receive routine PSA. Under the Affordable Care Act, insurers are required to cover preventive services that receive a "B" grade or higher from USPSTF without cost sharing.

    According to "Shots," USPSTF decided to change its recommendations for men ages 55 to 69 in light of new research on PSA tests. Specifically, the European Randomized Study of Screening for Prostate Cancer found that PSA testing reduced the chances that men would develop advanced-stage prostate cancer by about 30 percent and reduced the risk men would die from prostate cancer by about 20 percent, "Shots" reports.

    In addition, resent research has shown that more men diagnosed with prostate cancer are choosing to forgo treatment and instead monitor the disease, according to "Shots." USPSTF in the draft statement said that new approach reduces the potential harms related to routine PSA screening.

    USPSTF Chair Kirsten Bibbins-Domingo, a medical professor at the University of California-San Francisco, said, "The new evidence allowed us to say that, on balance, we think now the benefits do outweigh the harms." She added, "Therefore, what we are recommending is that doctors and patients talk together about whether screening is right for them."

    However, the task force in the draft statement warns that routine PSA screening is associated with potential harms, such as patient stress related to falsely positive test results, as well as potentially unnecessary and dangerous biopsies related to false-positive results.  Further, the task force stated that even if a PSA test identifies a cancerous tumor, many prostate cancers grow very slowly and might not ever become life-threatening. Men could undergo radiation and surgery for such tumors as a result of the test results, which could lead to incontinence or impotence, even though the treatments might not be needed, according to the task force.

    As such, USPSTF in the draft statement recommended against routine PSA testing for men ages 70 and older, saying the potential harms could outweigh the potential benefits for the age group. The task force in the draft statement retained the "D" grade it gave to PSA screening in men ages 70 and older in its 2012 recommendations, "To Your Health" reports.

    USPSTF is seeking public comment on the draft statement until May 8. According to the Associated Press, the task force is expected to issue final guidance months after the public comment period ends.

    Stakeholders express mixed reaction

    Physicians who have supported routine PSA screening praised the draft statement.

    Otis Brawley, CMO at the American Cancer Society, said the draft statement achieves the right balance. "I really do think that there is a pendulum in a lot of things that we do in medicine," he said. "And the pendulum here may be getting to the right place where we realize there are harms and there are benefits and individuals need to weigh these harms and benefits and tailor a decision that's right for them."

    Men are taking a 'wait and see' approach with prostate cancer. But is it safe?

    AUA President Richard Babayan called the recommendations included in the draft statement "thoughtful and reasonable," noting that they "are in direct alignment with AUA's clinical practice guidelines and guidelines from most other major physician groups."

    William Catalona, a professor of urology at Northwestern University's Feinberg School of Medicine, called the proposed recommendations in the draft statement "a victory for PSA screening for prostate cancer," which he said can "sav[e] lives." However, Catalona said USPSTF should expand the recommendations to encourage PSA screening beginning at age 40 and continuing past age 70.

    Meanwhile, some physicians expressed concern that the proposed recommendations could be misinterpreted as a suggestion that all men ages 55 to 69 should undergo PSA screening instead of deciding on the matter with their doctors.

    Dan Merenstein, a family medicine doctor at Georgetown University, said, "What I'm afraid of is that rather than having this discussion—because it's a difficult and long discussion—physicians will just order this test like they do ... a cholesterol panel. And that will cause many more harms than good" (Stein, "Shots," NPR, 4/11; Tanner, AP/Sacramento Bee, 4/11; McGinley, "To Your Health," Washington Post, 4/11; Bankhead, MedPage Today, 4/11).

    Advisory Board's take

    Deirdre Saulet, Oncology Roundtable

    The USPSTF faced backlash from many professional organizations in 2012 when it recommended against routine PSA screening for all men. Since that announcement, however, PSA testing has declined—indicating that at least some providers followed that guidance.

    The new draft recommendation is sure to add to the ongoing controversy and confusion around PSA screening. Leaders need to ensure patients and providers understand the risks and benefits of testing so they can reach informed, individual decisions. But this is easier said than done.

    To start, organizations should come to consensus on guidelines by understanding their community's needs and providers' preferences. Make sure providers understand the pros and cons of testing, and find ways to make it easier to identify eligible patients, such as via EHR alerts. Then, host education sessions in your community to review information on screening and answer questions, and provide decision support tools to help men decide whether or not screening is right for them.

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