Guidelines

USPSTF advises against widespread prostate cancer screening

 

Key clinical point: PSA-based screening for prostate cancer in men aged 55-69 years has limited benefits and significant risks.

Major finding: Overdiagnosis occurred in approximately 21%-50% of cancers identified during PSA screening.

Study details: The evidence report was based on 63 studies including 1.9 million men.

Disclosures: The research was funded by the Agency for Healthcare Research and Quality. The researchers had no financial conflicts to disclose.

Source: JAMA. 2018;319(18):1901-13. Fenton J et al. JAMA. 2018;319(18):1914-31.
 

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Selectively screen those who could benefit

The new USPSTF guidelines take a thoughtful approach to assessing the pros and cons of PSA-based prostate cancer screening and highlight the importance of identifying subgroups who could most benefit from screening and treatment, H. Ballentine Carter, MD, wrote in an accompanying editorial.

“Patients, together with their physicians, should decide whether prostate cancer screening is right for the patient. In this regard, primary care physicians have an important role in reducing the harms associated with screening and could consider a number of factors in this decision process,” he said.

In particular, Dr. Carter noted that men aged 55-69 years without multiple comorbidities would reap the greatest benefits from screening, while those aged 70 years and older would be more susceptible to the harm associated with testing and treatment and should be screened rarely. He also endorsed a 2- to 4-year screening interval to help reduce false-positive test results and overdiagnosis.

“By virtue of their relationship with patients, primary care physicians are in a unique position to help ensure that men diagnosed with favorable-risk disease (Gleason score 6 cancer grade on biopsy, and PSA level less than 10 ng/mL) are presenting a balanced message regarding management options,” with active surveillance as the preferred choice, he said. (JAMA. 2018. May 8;319[18]:1866-8).

Dr. Carter is Bernard L. Schwartz distinguished professor of urologic oncology and professor of urology at Johns Hopkins University School of Medicine, Baltimore, and had no financial conflicts to disclose.


 

FROM JAMA

The USPSTF recommends that, to reduce the risk of false positives and unnecessary complications from prostate cancer screening and treatment, physicians and their male patients aged 55-69 years should review together the pros and cons.

Clinicians should not conduct prostate cancer screening in men aged 55-69 years who do not ask for it (level C recommendation), according to the USPSTF recommendations, published in JAMA, which also recommend against any prostate cancer screening for men aged 70 years and older (level D recommendation). The recommendations replace those from 2012, and upgrade the statement against routine screening from a D to a C.

“The change in recommendation grade further reflects new evidence about and increased use of active surveillance of low-risk prostate cancer, which may reduce the risk of subsequent harms from screening,” according to the USPSTF.

The recommendations apply to asymptomatic adult men in the general United States population with no previous diagnosis of prostate cancer, as well as those whose ethnicity or family history put them at increased risk of death from prostate cancer.

In the evidence report published in JAMA, Joshua J. Fenton, MD, professor in the department of family and community medicine of the University of California, Davis, Sacramento, and his colleagues reviewed 63 studies comprising 1,904,950 individuals. The researchers examined the findings for information including the effectiveness of PSA screening and the potential harms associated with both screening and cancer treatment if disease was identified.

Overdiagnosis of prostate cancer ranged from 21% to 50% for cancers detected by screening, and one randomized trial of more than 1,000 men found no significant reduction in mortality for prostatectomy or radiation therapy compared with active monitoring.

Overall, men randomized to PSA screening had no significant reduction in risk of prostate cancer mortality in trials from the United States or the United Kingdom, although data from a European trial showed a significant reduction. Complications requiring hospitalization occurred in 0.5%-1.6% of men who had biopsies after screening showed abnormal results.

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