USPSTF releases new guidance about prostate cancer screening


Earlier today, the US Preventive Services Task Force (USPSTF) issued the final version of its revised guidance on screening for risk of prostate cancer. The basic recommendation statement can be found here. The full texts of all relevant documentation can be accessed here.

While there are going to be people who remain unhappy with this new set of recommendations from the USPSTF, your sitemaster suspects that everyone can agree that this is a much better set of guidelines that the last one (issued in 2012).

At the most basic level, the USPSTF now accepts the premise that, for men aged 55 to 69 years, the question of whether to get tested for risk of prostate cancer should be an individual one for every man, and that for that decision to be made appropriately, an individual man needs to be able to have an appropriate discussion with a well-informed physician (based on an overall C recommendation from the USPSTF).

The places where people are going to feel less comfortable are going to relate to men who — for whatever reason — feel that they are either at higher risk for diagnosis of prostate cancer at less than 55 years of age or continue to be at risk from a diagnosis of prostate cancer at 70 years or older because they have a life expectancy of well over 10 additional years.

The “New” Prostate Cancer InfoLink is — in all honesty — of the opinion that any man who thinks he is at high risk for prostate cancer should be able to get as PSA test after the age of 40 if he wants one (so long as this decision is made by someone who is clearly sane). In the USA this would include all black men of sub-Saharan African ethnicity; all men with two or more close relatives diagnosed with prostate cancer; all men with one close relative who had actually died of prostate cancer; and all men who are from families that carry the BRCA1/2 genes. While all such men may not need such a test, it would seem unethical to us to refuse to test such men.

Similarly, The “New” Prostate Cancer InfoLink also feels that men of 70 to 85 years of age should be able to request PSA testing if they are otherwise in good health and have a life expectancy in excess of 10 years. Again, we would consider it unethical to refuse to test such men (especially if they had any other additional risk factors).

We would carefully point out that the USPSTF recommendations are general in nature. What they state is that they do not recommend testing for all men outside the 55- to 69-year-old age range. They also do not tell primary care physicians (or any other physicians) that they should refuse PSA testing for others. They are merely stating that the available evidence does not justify a recommendation for testing.

The “New” Prostate Cancer InfoLink wishes to be very clear that we praise the USPSTF for a much more thorough process of reviewing data and for consideration of the input of appropriate professional and patient organizations that was evident in the development of the 2012 guidance document. While we may not agree 100% with every word in the USPSTF documentation we are very willing to accept the USPSTF’s decisions, even in the special cases where we believe that there is reasonable opportunity for polite disagreement.

6 Responses

  1. I absolutely endorse all of Sitemaster’s suggestions — and we rarely agree on screening and testing!!

    I read these recommendations last week under embargo and was most upset that men over 70 are considered toast. Just this morning I had one of our guys with Mx disease write me that his brother’s doctor refused a PSA test, because he was 70. Our participant was recently dignosed in his late 60s.

    Men over 70 can also be high-risk and they too should be tested whether or not they have a 10-yr life expectancy. There are enormous considerations to be explained to these folks, since 70% are likely to have some degree of prostate cancer. But if they still want a test, they should get it.

  2. Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men.

    Unfortunately the USPSTF bases its claim of a “small potential benefit” on a non-competent statistical analysis by the ERSPC that is based on an unproven null hypothesis assumption of homogeneity across the seven trials of the ERSPC. The ERSPC claims that it has proven this null hypothesis with a chi-squared test of homogeneity but incompetently ignores the basic fact that you can’t prove the null hypothesis by not rejecting it. See, for example, here.

    We are left with the fact that there is no “small potential benefit” proven anywhere except in two isolated trials in Sweden and the Netherlands (who withhold trial data) despite attempts to prove any benefit in many other countries.

    The USPSTF is being hugely deceptive to men by claiming there is a “small potential benefit” when there is no proven basis for such a claim.

  3. (1) I did point out that not everyone was going to be happy about this guidance!

    (2) I agree with Mr. O’Neill that the data from the ERSCP is simply data from a meta-analysis of seven dissimilar trials (and I have said this for years), and that it’s findings are consequently open to considerable question.

    (3) I would point out, however, again, that the USPSTF is not recommending that anyone gets tested for their risk of prostate cancer. What they are saying is that if you want to do this between the ages of 55 and 69, that’s fine, but you should do so only after a discussion with your doctor and that there are significant upsides and downsides to doing this.

  4. Hello,

    Thank you for the post!

    It seems to me that patient advocacy needs more voice in these medical recommendations. The medical community believes they are justified to be so wishy-washy because the research is so weak (hence the grades of C or D). But I feel that I must disagree because a simple “common-sense” benefit-cost analysis easily justifies the cheap PSA test compare to huge medical morbidities and associated costs. I suspect that is why the American Cancer Society recommends starting earlier than the doctors (even age 50 seems barely adequate).

    What I wonder is why more men do not know about these prostate cancer issues? Are we in denial? Where is the educational component needed to increase awareness? Am I missing something?

    Again, Sitemaster, thank you.

    Steven
    A PCa Survivor

  5. Dear Steven:

    (1) I can assure you that patient advocates contributed massively to the development of the most recent set of guidance from the USPSTF, but data are critical and the data are weak.

    (2) Yes. Most men are simply in denial — about almost all of their health risks — see my comment here about the results of the largest screening trial ever carried out and reported earlier this year. The most salutary result of this trial was that 74% of the men who were invited to have a PSA test never went to have one!

    (3) The amount of information that is now available about the value of testing — especially for men with an y type of individual risk for prostate cancer (race, age, family history) is enormous … but if your only intellectual interest is in the football or the baseball pages of the newspaper, why would you ever see it?

    Men who have been diagnosed with prostate cancer suddenly start to see the point. But the question I would ask you is, what did you know before you got diagnosed?

  6. Sitemaster,

    Thank you for your reply! I love this web site because y’all seem so engaged with your readers.

    I didn’t know much about prostate cancer before diagnosis. I try to trust my doctor with these issues, sorry but there are just too many diseases to keep up with. So I go for annual checkups, try to exercise and eat right, and leave the rest to my docs. So I get your point.

    Still, IMHO, ACPA seems to equivocate with insufficient reason. As I said, even with no data, a simple cost/benefit analysis would justify the very simple, cheap, non-intrusive PSA test.

    Peace.

    Ciao,

    Steven

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