番茄社区

In finalizing its draft recommendations for prostate cancer screening in men ages 55 to 69, the U.S. Preventive Services Task Force (USPSTF) has put itself broadly in alignment with guidelines from other organizations.

The USPSTF now recommends that for this age group, the decision to be screened for prostate cancer with prostate-specific antigen (PSA)-based testing should be an individual one, reported USPSTF Vice Chair Alex H. Krist, MD, MPH, of the Virginia Commonwealth University in Richmond, and colleagues in .

"We're recommending that men in this age group, 55 to 69, who are considering screening for prostate cancer, talk with their clinician, understand the benefit, understand the harms, and make a decision about what's right for them based on their values and their preferences," said Krist during an released with the new USPSTF recommendations and supporting them.

The USPSTF's shift for this age group comes in part due to newer evidence from the European Randomized Study of Screening for Prostate Cancer (ERSPC) trial, which showed that for every 1,000 men screened, 3.1 cases of metastatic disease were prevented. At a median follow-up of 12 years, ERSPC showed that the cumulative incidence of metastatic prostate cancer was lower among men randomized to the screening arm versus those in the control arm (relative risk 0.70, 95% CI 0.60 to 0.82).

"I think this is definitely a step in the right direction and more in line with the guidelines on prostate cancer screening from other organizations," Stacy Loeb, MD, of the NYU Langone Medical Center in New York City, told 番茄社区. "It is very important that men are informed about the benefits and harms of screening, and that their preferences are taken into consideration."

The Task Force's widely debated 2012 guidelines recommended against screening in men ages 55 to 69 (grade D). In 2013, guidelines from the American Urological Association (AUA) and the American College of Physicians recommended a shared decision-making approach for men ages 55-69 and in men ages 50-69, respectively.

"Although PSA is not a perfect test, there are many new testing options that can be used in men with an elevated PSA to help make decisions about biopsy." said Loeb. "These include marker tests that are more specific for clinically significant prostate cancer and magnetic resonance imaging."

The USPSTF described the number of harms and benefits with PSA screening, which can be quantified over a 10- to 15-year period.

It is estimated that for every 1,000 men offered PSA testing, 240 will have a positive result, leading to positive biopsies in 100. But 20.7% to 50.4% of these men will actually have indolent disease that never grows or metastasizes, according to the evidence report.

Of those 100 men positive for prostate cancer on biopsy, 80 will opt for definitive treatment with surgery or radiotherapy, either immediately or after a period of active surveillance. Following treatment, 50 of these men will experience long-term erectile dysfunction and 15, long-term urinary incontinence.

And while 1.3 deaths from prostate cancer will be prevented, five will still die from the disease despite having undergone treatment.

Krist said that one of the most "critically important" points amidst the data is that "whether screening is right for a man really depends on how they value these potential benefits and these potential harms."

In the recommendations, the USPSTF acknowledges that certain groups of patients are at higher risk of developing prostate cancer -- African Americans and those with a family history of prostate cancer -- but the Task Force doesn't suggest a different approach for these men due to a lack of evidence in the trials. Instead, they suggest that these risk factors be discussed with patients during the conversation about the risks and benefits of screening.

"The Task Force found itself in this position that we really couldn't say whether African American men would get any greater benefit from screening, and we really don't know if they'll have any greater harms from screening," said Krist. "We need more studies to understand the benefits and the harms so that clinicians can better counsel patients."

For men ages 70 and older, the new USPSTF recommendations remain unchanged, recommending against screening (grade D). In a statement, AUA President J. Brantley Thrasher, MD, broadly commended the new guidance but touched upon the guidance for this age group.

"While we agree that a number of older men are not candidates for prostate cancer testing, we believe that select older, healthier men may garner a benefit," said Thrasher. "We urge those men to talk with their doctors about whether prostate cancer testing is right for them."

In a editorial that accompanied the USPSTF recommendations, Anita D. Misra-Hebert, MD, MPH, and Michael W. Kattan, PhD, of the Cleveland Clinic in Ohio, noted that even with recommendations from the AUA and other cancer organizations, shared decision-making has not significantly increased for prostate cancer screening and there are obstacles in doing so.

"What the updated USPSTF recommendations for prostate cancer screening are asking of physicians is to take time to pause, explain what is currently known, understand patient preferences, and make the screening decision together," explained Misra-Hebert and Kattan. "It is clear that these types of conversations are a necessity to deliver optimal patient care even while there does not appear to be enough time or any specific incentives tied to engaging in these discussions."