PSA screening rejected by US screening Task Force
MedWire News: Healthy men should no longer receive prostate-specific antigen (PSA) screening for prostate cancer according to a final recommendation from the United States Preventive Services Task Force (USPSTF).
The recommendation, which replaces the 2008 version, was published following a period of public comment in which many people urged the USPSTF to change the recommendation from grade D ‑ meaning that physicians should not offer the test because the harms outweigh the benefits ‑ to grade C, meaning physicians could provide the test to patients who request it.
However, since no new evidence was presented, the recommendation remains unchanged. It applies to men in the general US population regardless of age, but does include the use of the PSA test for surveillance after diagnosis or treatment of prostate cancer.
In making their recommendation, published in the Annals of Internal Medicine, the USPSTF considered two major trials of PSA testing in asymptomatic men to assess the life-saving benefits of PSA testing.
The first trial, conducted in the USA, did not demonstrate any prostate cancer mortality reduction as a result of screening. The second trial, conducted in seven European countries, found a reduction in prostate cancer deaths of about one death prevented per 1000 men screened in a subgroup of men aged 55 to 69 years. However, five of the seven countries reporting results did not find a statistically significant reduction in deaths.
Conversely, the Task Force found "convincing" evidence that PSA screening is associated with significant harms. Nearly 90% of men with PSA-detected prostate cancer undergo early treatment with surgery, radiation, or androgen-deprivation therapy. However, up to five in 1000 men will die within one month of prostate cancer surgery and between 10 and 70 men will survive, but suffer life-long adverse effects such as urinary incontinence, erectile dysfunction, and bowel dysfunction.
"Many men are being subjected to the harms of treatment of prostate cancer that will never become symptomatic," say the authors.
Marc Rendell (The Creighton Diabetes Center, Omaha, Nebraska, USA) and co-authors of an accompanying editorial say that the USPSTF recommendation has underestimated the benefits and overestimated the harms of prostate cancer screening. They argue that the Task Force ‑ whose panel "does not include urologists or cancer specialists" ‑ largely bases its recommendations on flawed studies with inadequate follow-up time. In addition, the Task Force recommendations focus on mortality and do not take into consideration the substantial illness related to living with advanced cancer.
However, according to Otis Brawley (American Cancer Society, Atlanta, Georgia, USA), author of a second accompanying commentary, overdiagnosis makes screening seem to save lives when it truly does not. "It is my hope that the current USPSTF recommendation ends mass screening. Although recommending against routine screening, the Task Force does leave room for it within the physician-patient relationship," he says.
Indeed, Task Force chair Virginia Moyer (Baylor College of Medicine, Houston, Texas, USA) said in a press statement: "The USPSTF recognizes that clinical, policy, and coverage decisions involve more considerations than evidence alone. Clinicians and health care providers should understand the evidence but individualize decision-making to the specific patient or situation."
By Laura Cowen