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From the Summer/Fall 2018 Quest
The debate over PSA screening has been tumultuous, with many twists and turns. ©Sanford Radom, M.D.
The U.S. Preventive Services Task Force (USPSTF) released its final updated recommendations for prostate cancer screening in May. In a move away from the controversial 2012 guidelines, the new recommendations emphasize shared decision making between doctor and patient. Yet, the discussions over PSA testing are bound to continue, as the USPSTF still recommends against screening older men for prostate cancer and does not offer specific screening guidelines for men in populations at higher risk of developing prostate cancer.

The updated USPSTF recommendations encourage men aged 55 to 69 years to practice "shared decision making," in which the patient and his doctor discuss the potential benefits and harms of PSA screening and decide together if the patient should undergo PSA testing. This differs from the USPSTF 2012 statement, which recommended against PSA screening for all men, regardless of their age or race.

The panel based the updated guidelines on their analysis of scientific evidence published since 2012, when the task force's last recommendation was released. The panel weighed the harms and benefits of PSA testing, citing harms as overdiagnosis and overtreatment of the disease.

What's missing from the Task Force's recommendations?

The updated guidelines still fall short for men who may have an increased risk of developing prostate cancer, including older men, African American men, and men who have a family history of the disease.

For men aged 70 and older, the USPSTF recommends against PSA testing. However, many older men have a life expectancy of more than 15 years, indicating they would live long enough to benefit from prostate cancer screening. Older men are also more likely to have aggressive prostate cancer that grows and spreads quickly. Nearly half of U.S. prostate cancer deaths occur in men diagnosed after the age of 74 years, even though men in this age group comprise only approximately one quarter of prostate cancer patients.

The USPSTF recommendation against screening older men differs from the American Urological Association (AUA) recommendation, which notes that healthier men 70 or older may benefit from screening. The Prostate Cancer Foundation advocates for a more "personalized approach" that takes into account an older man's health, values, and preferences regarding PSA testing.

In addition, the USPSTF does not recommend more intensive screening for African American men. The panel cited a lack of direct evidence demonstrating that African American men would see a greater benefit from screening. However, it is well documented that African American men are more frequently diagnosed with advanced prostate cancer and are more likely to die from prostate cancer. A modeling study found that African American men are more likely to develop prostate cancer at a younger age and more likely to progress to metastases or a higher stage before being diagnosed. This suggests that African American men should consider beginning screening earlier and/or more frequently. The Prostate Cancer Foundation recommends that African American men talk to their doctors about baseline PSA testing at age 45.

The USPSTF also does not include recommendations for more intensive screening for men with a family history of the disease, such as men whose fathers or brothers died of the disease or were diagnosed at a young age. There is compelling evidence that these men have a higher risk of developing prostate cancer, and thus would benefit from screening. In the PLCO trial, men with a positive family history of prostate cancer had a 56% higher prostate cancer detection rate and a 51% higher prostate cancer mortality rate.

The USPSTF recommendations also exclude baseline testing a man in his 40s, although research shows this can be the strongest predictor of metastases and death from prostate cancer decades later. Men in the top 10% PSA levels for their age group account for almost half of all prostate cancer deaths up to 30 years later, and men with levels of 1.0 ng/mL or higher in their 40s should be more carefully monitored as they get older. Other groups include baseline testing in their recommendations. For example, the Prostate Cancer Foundation recommends men with a family history of the disease should discuss baseline testing with their doctors beginning at age 40.

 

Dr. Catalona's Opinion

Willian J. Catalona, M.D.

The controversy over PSA screening has not ended despite unequivocal evidence that it saves lives. The USPSTF's 2018 recommendation is a step in the right direction, but there is more progress to be made. My additional recommendations for PSA testing include baseline testing men in their 40s to assess future risk for clinically significant prostate cancer; testing high-risk men earlier than age 55, including African American men and men with a family history of the disease; and testing healthy men 70 years or older. Also, if a man asks his doctor whether or not he should have a PSA test, the doctor should encourage appropriate testing.

In interpreting PSA test results, age-specific PSA cutoffs should be used to help determine whether a man has an elevated PSA level. Also, testing intervals should not exceed 1 to 2 years, because less frequent PSA testing limits the ability to detect aggressive cancers before they spread out of the prostate.

With early detection, men have a greater chance of finding and treating prostate cancer before it spreads. During the PSA screening era (1991-2008), there was an 80% decrease in the percentage of men who had advanced prostate cancer at the time of diagnosis, and a 53% decrease in the prostate cancer death rate.

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