To Screen or Not to Screen: New Recommendation Draft for Prostate Cancer Screening

By Azelia Brown, Doctor of Pharmacy Candidate Class of 2017

Prostate cancer in the U.S. is the second most common cancer in men and the third leading cause of cancer death in men.  An estimate from the American Cancer Society states that there will be about 161,360 new cases of prostate cancer and 26,730 deaths in 2017. [1]  The prostate-specific antigen (PSA) screening test is claimed to have changed prostate cancer diagnosis, allowing for earlier diagnosis in more curable stages of the disease. [2]  The U.S. Preventative Services Task Force has called into question current screening practices.  It was reported that PSA-based screening is associated with potential overdiagnosis and overtreatment, possibly leading to urinary, sexual, and bowel-related treatment adverse effects. [3]

The 2012 U.S. Preventative Services Task Force (USPSTF) recommendation statement gave a grade D recommendation (benefits no greater than harms) to PSA-based screening for prostate cancer.  It was indicated that 0 to 1 death per 1000 men was prevented with PSA- based screening and did not recommend PSA screening for all men. For patients who still requested PSA screening, it was stated that patients should “be provided with the opportunity to make informed choices to be screened that reflect their values about specific benefits and harms.[4]  

In the 2017 draft recommendation, it was estimated that greater than 1 patient in 1000 will avoid death due to PSA-based screening and 3 men in 1000 will avoid metastatic disease. The 2017 draft recommendations assigned a grade C recommendation (small net benefit) that PSA-based screening should be an individualized decision after a discussion with a clinician about the benefits and harms of screening. The 2017 draft recognized that patients may be more likely to appreciate the benefits of screening and believed this new guideline to better empower both patient and physician. [3]

By increasing the screening recommendation from “benefits no greater than risks” to “small net benefit”, this could trigger an increase in PSA-screening.  Although the wording change is slight, increased screening may lead to more misdiagnosis and overtreatment.  The new recommendations do not provide a definitive guide for the management of these patients, which may be confusing for practitioners.  Healthcare practitioners should also consider if the added costs are worth the benefit.  However, the new grade C recommendation may allow for more men to discuss their care and develop a plan that is consistent with their goals.  

The new recommendations may prove beneficial for men with increased risk of prostate cancer or those who have not been extensively studied.  For example, African American men represent 12.6% of the U.S. population but only represent 4% of the cohort in the largest clinical trial on PSA screening.  Even though this population may be at a higher risk for prostate cancer, recommendations are difficult with such a small sample. By putting more emphasis on informed decision-making through the patient-physician relationship, early detection and survival may be improved in these populations.  The USPSTF plans to review public commentary for revision and inclusion of the most relevant information for the final recommendation statement.

References

[1] Key Statistics for Prostate Cancer | Prostate Cancer Facts. American Cancer Society. https://www.cancer.org/cancer/prostate-cancer/about/key-statistics.html. Last revised January 5, 2017. Accessed April 16, 2017.

[2] Wolf, AMD., Wender, RC, Etzioni, RB, et. al.(2010), American Cancer Society Guideline for the Early Detection of Prostate Cancer: Update 2010. CA: A Cancer Journal for Clinicians, 60: 70–98. doi:10.3322/caac.20066.

[3] Bibbins-domingo K, Grossman DC, Curry SJ. The US Preventive Services Task Force 2017 Draft Recommendation Statement on Screening for Prostate Cancer: An Invitation to Review and Comment. JAMA. 2017.

[4] Moyer VA, on behalf of the U.S. Preventive Services Task Force. Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2012;157:120-134. doi: 10.7326/0003-4819-157-2-201207170-00459.

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