番茄社区

Medical opinion about prostate cancer screening inched closer to harmony with an updated draft recommendation from the U.S. Preventive Services Task Force (USPSTF) supporting discussion-backed decisions for men, ages 55 to 69.

In 2012 the task force recommended against (grade D) routine screening with PSA tests for men of any age. The position put the USPSTF at odds with the American Urological Association (AUA) and, to a lesser extent, the American Cancer Society (ACS), both of which supported decision making based on clinician-patient discussion.

The to the USPSTF screening recommendation supports an individualized approach to screening, based on clinician-patient discussions about the potential harms and benefits of screening (grade C recommendation). The USPSTF submitted the recommendation for public comment, which ends May 8.

In the intervening 5 years, new data came to light, shifting the consensus pendulum in favor of a discussion-based approach, albeit slightly, said USPSTF member Alex H. Krist, MD.

"In 2012 and now, there was a close balance of benefits and harms," Krist, of Virginia Commonwealth University in Richmond, told 番茄社区. "Since 2012, there have been a couple of things that emerged that we didn't know then. With longer follow-up in the U.S. and European [screening] trials, we've seen that slightly fewer men will die of prostate cancer if they're screened. That's a very slight increase."

"The other thing we have now is evidence that three men who would have developed metastatic prostate cancer won't have metastatic prostate cancer with screening," he added. Specifically, the new evidence showed that screening PSA tests would prevent three cases of metastatic prostate cancer and one or two prostate cancer deaths.

The ACS and the AUA both welcomed the USPSTF support for individualized decision making about PSA-based prostate cancer screening.

"The draft recommendations released today are thoughtful and reasonable and are in direct alignment with the AUA's clinical practice guidelines and guidelines from most other major physician groups," AUA president Richard K. Babayan, MD, of Boston University, said in a statement.

"The USPSTF clearly utilized a more inclusive and transparent process in developing these draft recommendations," Babayan continued, alluding to criticisms of the lack of medical specialty representation on the task force. "This process demonstrates how the task force, specialists, patients, and the medical community as a whole can work together to develop recommendations that better reflect the clinical and research landscapes."

ACS chief medical officer Otis Brawley, MD, said he's "thrilled" that the USPSTF, AUA, ACS, and other organizations are becoming more like minded about prostate cancer screening. The only real difference is that the task force and AUA suggest that the discussions begin at age 45, whereas the ACS recommends starting the discussion process at age 50.

However, Brawley emphasized an issue that has often gotten lost in the controversy about when and how to begin PSA-based screening for prostate cancer.

"I hope the lay public and the doctor community understand that the harms of prostate cancer screening are better proven than the benefits," Brawley told 番茄社区. "It's never been that there's no benefit to prostate cancer screening. The problem has always been these harms."

The USPSTF recommendation reflected a response to the "sea change" in American medicine; the "knee jerk" reaction of the need for immediate treatment; and the emergence of active surveillance as an option for many men with early-stage prostate cancer.

"In the 1990s, we would tell people, 'You need to be treated, and you need to be treated in the next 10 days,'" said Brawley. "Now a large proportion of men in the United States with prostate cancer, 'You can be watched.' More than half of all men with screen-detected prostate cancer can be watched and will never need to be treated."

Krist agreed that emerging data on active surveillance played a role in the updated recommendation.

"We have data now showing that active surveillance can save the same number of men from dying of prostate cancer; that there isn't an increased number of prostate cancer deaths with active surveillance compared with radiation or surgery," said Krist. "Active surveillance can reduce the potential harms in this whole screening-and-treatment pathway."

In reviewing new data, the USPSTF compared potential harms and benefits of PSA-based screening for men, ages 55 to 69, followed for 10 to 15 years. The panel found that for every 1,000 men screened (or offered PSA screening), 240 would have a positive result. Positive results would lead to positive biopsies in 100, and 80 of the 100 men would opt for definitive surgery or radiotherapy (65 immediately and 15 after a period of active surveillance).

The panel noted that "Many men will learn they have a false-positive result after getting a biopsy. The potential side effects of biopsy include pain, bleeding, and infection."

Of the 100 men with a positive biopsy, "20% to 50% of these men will have cancer that never grows, spreads, or harms them." Of the 80 men who opt for definitive treatment, "60 or more will experience serious complications [including] urinary incontinence and/or sexual impotence."

Despite support for discussion-driven decision making, a recent study showed that a third of men did not discuss the pros and cons of PSA tests with clinicians prior to testing. Krist said the findings disappointed but did not surprise him.

"Only by incorporating a man's values and preferences into the decision-making process can we make the right decision," he said. "It's extremely important for physicians to discuss this with patients, and patients really shouldn't be getting a PSA test without understanding the benefits and the harms."

The recommendation applies to men who have an increased of prostate cancer because of family history or race, as well as to average-risk men. The USPSTF did not change its recommendation against PSA-based screening for prostate cancer in men ages ≥70, finding that the potential benefits did not outweigh the potential harms.

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