The dilemma of prostate cancer screening recommendations

The dilemma of prostate cancer screening recommendations

In recent years, prostate cancer screening has been the hot topic among urologists and medical community. There has been a massive increase in the detection of prostate cancer following population based screening use of prostate specific antigen (PSA). The follow up studies at 10 and 15 years demonstrates high survival rates for multitude of treatment options including conservative managements (watchful waiting and active surveillance). These findings led to the concern of urologists on possible effects of over-diagnosis and overtreatment of prostate cancer. The main concern was that PSA screening for prostate cancer leads to the detection of indolent, low-grade prostate cancer that is not life threatening even in the absence of any treatment action. In 2012, the US Preventative Services Task Force (USPSTF) made a controversial recommendation against routine PSA-based screening for prostate cancer in all men. USPSTF claimed that based on research evidence the benefits of screening do not outweigh the harms and assigned a recommendation D grade to the PSA screening practice. Despite this claim, many urologic and oncologic associations recommend in their guidelines the use of PSA based on patient risk factors. The recommendation is that the decision should be made after the doctor makes a through discussion of pros and cons of PSA screening with the patient.

Now, after five years, the USPSTF through a systematic review of the evidence and research of several modeling studies for over-diagnosis and overtreatment, has re-stated that the potential benefits and harms of PSA-based screening are closely balanced in men ages 55 to 69. The USPSTF revised the statement that doctors should make patients aware of the potential harms and benefits of PSA, and ultimately it’s each individual man’s decision to be screened or not. This revised recommendation is now based on physicians’ discussion with men in 55 to 69 age about the potential benefits and harms of screening, which makes this revised statement a C recommendation instead of a D recommendation.

Despite all said above, the publication of the draft form of the revised recommendation and asking for other societies and expert opinions on this recommendation is a positive move from USPSTF, better late than never. Now, it is clear how USPSTF reaches conclusions and provides an opportunity for other influential authorities to speak their voice and comment on the process. It may lead to future inclusion of the voices of experts’ society and associations in making recommendations on such pivotal topics, such as PSA.

Prostate cancer screening is not limit to urologists; family physicians and internists do screening of prostate cancer as well. A review of different guidelines of each medical society shows differences in the PSA use. The difference is mainly in the patient selection. For example, the USPSTF recommendation is against PSA screening in men under 55 and over 70, while National Comprehensive Cancer Network suggests a baseline PSA done between 45 and 49 and retesting for men between 50 and 70. While each society provides its own guideline, the work of USPSTF in publishing a draft, showing the evidence and process of reaching to such conclusions is a positive move that can benefit mostly patients. It might be the time for all the medical community, working and researching prostate cancer, to get together and promote a shared, single guideline to address the differences and controversies that exists between the guidelines.

It really boils down to how much value does a man place on the benefits of PSA screening versus the harms. Some men will be more willing to risk the possible harms of PSA screening that might lead to over-diagnosis or incontinence while others may place more value on reducing their chance of dying from the disease or the chance of it spreading by getting a PSA screening. A shared decision making while discussing risks, benefits and pitfalls of a PSA screening test with doctors, would be the ultimate approach in every patient encounter. This shared patient and doctor decision-making process can be backboned with evidence-based guidelines in performing or deferring a test.

There is no doubt that PSA screening catches prostate cancer at an early, more treatable stage. As seen in the USPSTF draft, a treatment plan, either surgical treatment or radiotherapy, decreases the chance of metastatic disease compared to conservative managements. Decision making based on mortality rate per se, might not be the wise and best indicator in dealing with prostate cancer. According to the evidence, the survival rate for prostate cancer is comparable among different treatment strategies, however, the side effects and risk of metastasis of each treatment modality is different. Thus, it is a wiser decision to differentiate treatment of men with higher risk of prostate cancer, such as African American and men with family history of prostate cancer. In other words, men who are disproportionately affected by prostate cancer – African American men and men with a family history and often underreported in the prostate cancer research – are given more attention to their particular needs.  Even though there is not enough evidence to make a specific recommendation of these two groups of men at this time, the USPSTF did emphasize the need for more studies in these populations. 

At the end, the whole process of discussing risk factors and making wise decisions about the best treatment for each individual patient, is an individualized process requiring a trustful relationship between the physician and the doctor.

Patients newly diagnosed with prostate cancer can contact world renowned prostate cancer surgeon and urologic oncologist, Dr. David Samadi. For a consultation and to learn more about prostate cancer risk, call 212-365-5000.