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24-05-2012 | Article

Task force recommends against routine PSA screening for prostate cancer

MedWire News: The US Preventive Services Task Force (USPSTF) has issued clinical guidelines recommending against the routine use of prostate-specific antigen (PSA)-based screening for prostate cancer.

"Although the precise, long-term effect of PSA screening on prostate cancer-specific mortality remains uncertain, existing studies adequately demonstrate that the reduction in prostate cancer mortality after 10 to 14 years is, at most, very small, even for men in what seems to be the optimal age range of 55 to 69 years. There is no apparent reduction in all-cause mortality," USPSTF members write in the Annals of Internal Medicine.

"In contrast," they add, "the harms associated with the diagnosis and treatment of screen-detected cancer are common, occur early, often persist, and include a small but real risk for premature death."

The task force members reviewed data from two large trials: the US Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial and the European Randomized Study of Screening for Prostate Cancer (ERSPC). PSA screening did not result in a reduction in prostate cancer mortality in the PLCO trial, and in the European trial the reduction was small, at approximately one death per 1000 men screened in a subgroup of men aged 55 to 69 years.

The authors note that in five of the seven countries contributing data to the ERSPC, screening was not associated with a significant reduction in cancer mortality, and that all-cause mortality was similar between screened and unscreened groups.

In an accompanying editorial, Otis Brawley, chief medical officer and executive vice president of the American Cancer Society, supports the recommendation.

"I believe that much of the shock about this recent recommendation is because Americans have been taught for decades to fear all cancer and that the best way to deal with cancer is to find it early and treat it aggressively. As a result, many have a blind faith in early detection of cancer and subsequent aggressive medical intervention whenever cancer is found. There is little appreciation of the harms that screening and medical interventions can cause," he writes in a related editorial.

Brawley and the USPSTF maintain that the potential for harm from detecting and treating cancers that otherwise may have been inconsequential appear to outweigh any potential benefit from the screening.

The recommendation does not sit well with several professional groups, however. In a second editorial, William Catalona (Urological Research Foundation, St Louis, Missouri) and other leading prostate cancer surgeons and physicians point out that the USPSTF panel does not include urologists or cancer specialists. The editorialists contend that "the USPSTF has underestimated the benefits and overestimated the harms of prostate cancer screening. Therefore, we disagree with the USPSTF's recommendation."

They question the methodology of studies the USPSTF relied most heavily on, and warn that the blanket recommendation against screening "could result in delayed diagnosis of curable cancer in young men who may then present with advanced disease, illness, and death."

The American Urological Association (AUA) was even more forceful in its objection. In a statement, AUA President Sushil Lacy expressed "outrage," saying that the recommendations are too broad, and do not take into account the possibility that certain subgroups of men might benefit from PSA screening.

"It is inappropriate and irresponsible to issue a blanket statement against PSA testing, particularly for at-risk populations, such as African-American men. Men who are in good health and have more than a 10-15 year life expectancy should have the choice to be tested and not discouraged from doing so," Lacy says.

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AUA statement

By Neil Osterweil