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U.S. Preventive Services Task Force Revisits Prostate Cancer Screening

Feature |
October 27, 2011

U.S. Preventive Services Task Force Revisits Prostate Cancer Screening

  1. Allan S. Brett, MD

In a preliminary draft, the USPSTF recommends against prostate-specific antigen screening.

  1. Allan S. Brett, MD

On October 11, 2011, the U.S. Preventive Services Task Force (USPSTF) posted a draft recommendation statement on screening for prostate cancer. In its 2008 guideline on this topic, the USPSTF concluded that evidence was insufficient to make a recommendation in men younger than 75, but it recommended against screening older men (age, ≥75). Now, 3 years later, the USPSTF recommends against prostate-specific antigen (PSA)-based screening for prostate cancer in all age groups.

The impetus for the USPSTF's revisiting of PSA screening is the recent publication of mortality results from two large randomized screening trials (JW Gen Med Mar 18 2009). A U.S. trial showed no benefit from screening but was tainted by substantial screening outside the trial in the control group. A European trial showed a small statistically significant reduction in prostate cancer mortality in screened men; however, substantial overtreatment occurred (i.e., a very small proportion of men who underwent surgery or radiation therapy ultimately benefited from these interventions), and critics have voiced concerns about certain methodologic issues in this trial, too. In reaching its decision, the USPSTF drew the following conclusions from its review of the evidence:

  • The magnitude of harms from screening (e.g., falsely high PSA levels, psychological effects, unnecessary biopsies, overdiagnosis of indolent tumors) is “at least small.”

  • The magnitude of treatment-associated harms (i.e., adverse effects of surgery, radiation, and hormonal therapy) is “at least moderate” — particularly because of overtreatment among men with low-grade disease.

  • The 10-year mortality benefit of PSA-based prostate cancer screening is “small to none.”

  • The overall balance of benefits and harms results in “moderate certainty that PSA-based screening . . . has no net benefit.”

I agree with this draft statement, which is a pre-release review and not the final recommendation. Public comment is invited through November 8, 2011, after which a final statement will be published. Nevertheless, the expected firestorm has erupted already. Advocates of screening have criticized the USPSTF analysis, and the American Urological Association issued a press release stating that “the USPSTF — by disparaging the [PSA] test — is doing a great disservice to the men worldwide who may benefit from the PSA test.” Journal Watch will cover the final recommendation when it is published.

Reader Comments (8)

Bernard A. Yablin

Why stop at age 75, considering the number of advanced cases that may show up after then?

Competing interests: None declared

Robert C. Barker

Does anyone still do rectal exams? Perhaps a carefully done rectal exam might be helpful in identifying those who might benefit from further testing and treatment. Perhaps some study might be carried out comparing outcomes of those screened by rectal exams and those by PSA.

Competing interests: None declared

JL Brown

There is a significant industry built up around prostate screening. Apparently, few men are benefiting from the test. More importantly, the test offers peace of mind to physicians and patients alike when it is negative. In my opinion, we need better screening options, and these are apparently not on the near horizon.

Competing interests: None declared

Neil K. Hall

It is amazing how many physicians can't or won't see the truth staring them in the face when in conflicts with their beliefs. Finally the USPSTF has returned to their long-ago position that PSA screenings actually are harmful overall. There never was good evidence that they improved overall outcomes for men. The fact that so many doctors don't support the very real evidence and protect our patients from the harms of this test is a sad comment about American Medicine.

Competing interests: None declared

matthew m. kreps

the proposal for PSA screening mentioned by Gros-Aymerich sounds somewhat promising. regardless, the comments made by Lederman and Ameen seem to miss the point however. "men going through life with our fingers cross" and individual examples of people who have been helped don't take into account evidence based medicine. the entire point is that while some people can be helped by this kind of testing, there are about the same number that are harmed by the treatment for their elevated PSA. 1) we could do an LP on every single person who comes into the hospital with AMS in the hopes of eradicating meningitis. 2) we could do a CT angiogram of the chest for everyone with shortness of breath to detect every PE. 3) we could do a cath on everyone who has chest pain. why don't we? because the number who benefit is equal to if not exceeded by those that are harmed. primum non nocere. this is why we take specific subgroups for whom a benefit is clearly demonstrated. this is why there is such a thing as the well's criteria for PE and the TIMI score for chest pain. the PSA would still have a role in following a known prostate cancer, but not for screening.

Competing interests: None declared

Hal Lederman

So the PSA test is not perfect. By the way, what else is there?? Are men supposed to wait until the cancer shows up by digital exam, just like in the good old days, when it may be too late? Mammograms have a lot of pitfalls too. Why do we men feel that going through life with our fingers crossed, and hoping for the best, is smart?

Competing interests: None declared

Jose GROS-AYMERICH

How many men would like never having a test that reassures them ?. H Lilja et al, from NY, published in 2011 ASCO Annual Meeting, Abstract 4512, a proposal for a new PSA screening strategy. Men would have an initial PSA test around 45 years of age, if PSA value is below a threshold ( Don't remember well, maybe 0.4 , those with higher values send to closer follow-up), just two more testing at 55 and 60 ( Figures to be checked ) will be enough for more than 40% of men. This can reduce costs and test related anxiety and additional testing. The issue on PSA screening may be that Prostate Cancer Specific Mortality started to decrease in coincidence with the introduction of PSA test. Or not ?

Competing interests: None declared

William O. Ameen, MD

Ask any of my patients, including an asymptomatic 37 yo and a 64 yo classmate of mine, among the several positive asymptomatic prostate cancer patients I find per year, whether it was worth it to be screened.

Competing interests: None declared

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