Feedback to USPSTF on new, draft recommendations on PSA screening


As many readers will be aware, the U.S. Preventive Services Task Force (USPSTF) recently issued new, draft guidance on the role of testing for risk of prostate cancer, and most particularly on the use of PSA testing in men of 55 years and older. All public comment on the proposed new draft recommendations is due on or before May 8 upcoming.

All relevant information about the new USPSTF draft guidance and the research that went into the development of this new draft guidance can be found if you just click here.

The USPSTF is proposing to alter the current guidance such that:

  • For men of 55 to 69 years, the USPSTF recommends that clinicians inform men ages 55 to 69 years about the potential benefits and harms of prostate-specific antigen (PSA)–based screening for prostate cancer (a so-called C recommendation).
    • The decision about whether to be screened for prostate cancer should be an individual one. Screening offers a small potential benefit of reducing the chance of dying of prostate cancer. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and impotence. The USPSTF recommends individualized decision-making about screening for prostate cancer after discussion with a clinician, so that each man has an opportunity to understand the potential benefits and harms of screening and to incorporate his values and preferences into his decision.
    • Specific clinical considerations may be relevant to screening in African American men and men with a family history of prostate cancer because these are populations at  higher risk for prostate cancer.
  • For men of 70 years and older, the USPSTF recommends against PSA-based screening for prostate cancer in men age 70 years and older (a so-called D recommendation).

In commenting back to the USPSTF on these proposed new recommendations, Prostate Cancer International (PCaI) has made the following statements:

  • Just as the new draft guidance document calls out the need for awareness about the particular risks associated with a family history of prostate cancer and with African-American race, PCaI believes there is a subset of men of  70 or more years of age who, because of a potential life expectancy of an additional 15 or more years, are also at risk for metastatic prostate cancer and/or prostate-cancer specific death.
  • We would like to recommend that, without changing the general recommendation against screening for men of 70 or more years of age (because we understand that currently available data are limited and show little to no benefit on average for most men of 70 or more years of age from prostate cancer screening), the USPSTF includes language within the full text of the proposed new recommendation that addresses:
    • The need for individual clinical decision-making regarding the appropriateness of PSA testing in men of 70+ years who have a life expectancy of another 15+ years and
    • The need for additional research into the appropriateness of such testing in such men of 70 or more years of age and a life expectancy of 15+ years.

Having said this, we have also asked the USPSTF to make it as clear as possible in all their communications on this issue that:

  • The USPSTF’s recommendations are designed to address what we know about the risks and benefits of PSA-based screening for prostate cancer among men in the US on average, and
  • The actual appropriateness of PSA-based testing for risk in any one individual should be based on discussions between that individual patient and his physician(s) that are specific to that patient’s clinical circumstances.

8 Responses

  1. This is what I think the USPFTF should tell a man (or clinician) about PSA testing (if I could underline and delete in this format to show the changes I made to the above quote, I would have):

    The decision about whether to be screened for prostate cancer should be an individual one. Screening offers a statistically small benefit of reducing the chance of dying of prostate cancer because most men who are diagnosed with prostate cancer have very slow growing tumors and a relatively short life expectancy. However, you should consider that in 2016, approximately 176,450 men were diagnosed with prostate cancer and about 27,681 men died from their prostate cancer in the United States. If prostate cancer is diagnosed before it escapes the gland, it is usually curable. Late stage diagnosed prostate cancer is not curable by any known treatment. Many men may experience harms of screening, but not from the PSA blood test itself. Instead, if the patient’s clinician does not properly counsel the patient, if he interprets the results of the PSA test incorrectly, or if he fails to recommend active surveillance when the tumor is slow growing and the patient has a limited life expectancy, the clinician may recommend and convince the patient to undergo unnecessary additional testing, biopsies, scans, and treatment, none of which are benign {no pun intended}. Prostate cancer treatment may have serious and permanent side effects and complications, such as incontinence, fatigue, scarring, osteoporosis, cognitive decline, nueropathy, and impotence. The USPSTF recommends individualized decision-making about screening for prostate cancer after discussion with a reasonably competent clinician, so that each man has an opportunity to understand the potential benefits and harms of screening and to incorporate his values and preferences into his decision.

    USPSTF: Place the blame where it lies and don’t kill the PSA messenger.

    Sitemaster,: Thank you for letting me vent!! :-)

    Best regards,

    Richard

  2. Dear Richard:

    Just as a side note to this, are you aware what percentage of men who are found to have low-risk prostate cancer as a consequence of a PSA test then insist on having active treatment when advised by their urologist and/or their radiation oncologist that simple monitoring (active surveillance) would be the recommended opinion? You might be surprised, and it would certainly dispel you implicit suggestion that most treatment for low-risk prostate cancer is being “pushed” on the patients by their doctors.

    Hindsight is commonly 20:20. The same is rarely true at the time of diagnosis.

  3. Sitemaster:

    You make a very good point (as usual), and perhaps another sentence could be added to address this aspect. However, I still do not see the PSA test as the culprit even if the patient rejects the reasonable advice of the clinician. It is the prerogative of the patient to ultimately make the decision, and while big brother (the USPSTF) might recommend to withhold information because the individual does not know what to do in his own best interest, I believe more information is better than less information, as long as it is presented truthfully. Only with honest and complete information can a patient’s utility be maximized. That’s why I subscribe to your Site!

    Best regards,

    Richard

  4. Dear Richard:

    My point is that you are speaking from experience and considerable knowledge. Most men have little to no knowledge of anything about prostate cancer prior to having their first PSA test. Thus, they have no good information on which to make almost any decisions about anything — however sound and wise (or horrible and bad) the guidance they are offered.

    The lack of knowledge is a fundamental problem when it comes to the implications of the next step — regardless of anything you, I, or the USPSTF may say or suggest. From that perspective, the PSA test is by no means a “benign” test because it can come with very serious consequences for patients with low levels of medical/scientific knowledge.

  5. Men 70 Years Old And Older Who Have Not Had A PSA Test In The Prior 10 Years

    There is a serious flaw in the draft recommendation for men 70 years of age and older that will almost surely cause many avoidable deaths that would be prevented (or at least delayed), adding some quality-of-life years) by PSA screening. The statistical evidence relied upon by the USPSTF to conclude negligible benefit for men aged 70 and older appears to be based on the screening arms of the ERSPC trial and its national cohorts where there has been at least some prior screening of men in the 70 and older group. (PLCO, which is irrelevant for other reasons noted by the current USPSTF, likely had a very substantial proportion with prior screening.)

    In the US in 2017, with the substantial decline in PSA screening in recent years due to the previous USPSTF recommendation, there is likely a substantial number of men aged 70 or older who have either never been screened or at least not screened in the previous ten years. Observation of the graphic evidence from the ERSPC makes clear that a large proportion of diagnoses of prostate cancer occur due to the first screening. Therefore, while there appears to be negligible benefit of rescreening for men of at least 70 who have been previously screened, especially in the fairly recent past, there could be a benefit, perhaps substantial, for those who have never been screened or not screened in their 60s, when diagnosis of prostate cancer Is much more common than in earlier decades.

    After all, as the USPSTF points out in the “fine print” text that is unlikely to receive attention from the media or overworked primary care physicians, “The median age of death from prostate cancer is 80 years, and more than two thirds of all men who die of prostate cancer are older than age 75 years.1” – from the “Rationale – Importance” section of the Recommendation.

    As life expectancy improves in the US, many generally healthy men of age 70 or older, like me at age 74, can expect to enjoy quite a few more years of life if that span is not cut short by late-diagnosed prostate cancer. This is particularly true now that radiation, aided by modern assessment and targeting imaging, is generally the treatment of choice for older men, has improved to the point that it can reliably knock out localized prostate cancer and is also effective against regional metastatic disease.

    The ever improving case assessment technology (including genetic, etc. testing), ever growing arsenal of more effective drugs, and ever increasing ability to put them to use also means better prospects for men with challenging cases diagnosed in their 70s. As a fourteen year veteran of intermittent triple ADT, I am familiar with the work of doctors expert in ADT who find that, for elderly men, a mild form of ADT, such as Casodex/bicalutamide plus Avodart/dutasteride, confers most of the benefit of ADT based on an LHRH-agonist or antagonist but with a generally low burden of side effects. Similarly, the rapidly growing acceptance of active surveillance, especially for older patients, minimizes the risks of overtreatment. Thus there are excellent options for older men with challenging cases that need some treatment.

    Therefore, the USPSTF needs to revise its recommendations to avoid discouraging screening for generally healthy men of age 70 or older who have never been screened or not screened in their 60s. Here are suggestions for the key recommended age blocks in the summary recommendation table:

    For the “C” recommendation: Men ages 55 to 69 years, and generally healthy men aged 70 to approximately 80 years who have not had a PSA test since age 59

    For the “D” recommendation: The USPSTF recommends against PSA-based screening for prostate cancer in men age 70 years and older if they have been previously screened since age 59 or are not generally healthy.

    This is basically what I included in one of my comments to the USPSTF on its draft recommendation on screening.

  6. Dear Jim:

    Once again. There is absolutely no good evidence whatsoever that PSA screening extends life or even prevents the onset of metastasis in men of 70 and more years of age. There is no way that the USPSTF could have given a C recommendation for such men. Once again, your opinions are based on no reliable data, and guidelines are data-based.

    Do we need better data on whether there is a benefit to PSA testing among men over 70 who have a life expectancy of 10 or more years? Yes. Sure we do. But your premises are entirely speculative, and that’s not useful to guideline development.

  7. Dear Sitemaster:

    My hope is that the USPSTF will recognize that the previous Task Force recommendation in 2012 discouraged men in the 60 to 69 age range from being screened; a lack of the encouraging evidence we now have from the ERSPC was also a factor back then. The recommendation has now changed to favorable, and the updated ERSPC evidence has become more favorable. Those men discouraged from screening are now five years older, with many in the 70 and over range. We know that evidence supports screening in the under 70 age range specifically the range from 55-69. The combination of these facts means that some men, probably a fairly large number, should have had significant cancer caught when they were in their sixties but did not as they, their physicians, or both were unenthusiastic about screening.

    That significant but undetected cancer has now had an average of several more years to grow, but, due to the relatively slow course of the disease for most men, is still likely treatable with good odds of success for many. It is those men who would be the beneficiaries of the change suggested in the previous post. The evidence really rests on research for screening in men under age 70, in other words the core 55-69 year group in the ERSPC, which in fact noted an increased impact in the 65-69 year group over other age groups, “most likely due to chance”.

    If the Task Force were to revise their summary along the lines I suggested, it would provide five years more time (before the next USPSTF update) for considerable maturing of the ERSPC results, which could give us data for judging whether the 70 and over group (likely with a cut point of just a few more years, such as 70-75) had results strong enough to stand on its own, without a grace period to compensate for the discouragement of screening over the past few years.

    I have given this 70 and over issue my best shot. It’s now up to the Task Force.

  8. Jim:

    You can wish as much as you like, but your wishes still don’t have data to support them.

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