By Jaya Mathur, MA, Senior Health Communication Manager, CommunicateHealth, Inc.
The U.S. Preventive Services Task Force (USPSTF) has recently released a new draft recommendation for prostate cancer screening. The draft recommendation encourages providers to inform men ages 55 to 69 about the benefits and harms of prostate cancer screening. That way, patients can work with their providers to make a decision about screening that’s right for them.
This is an update from the last version of the recommendation released in 2012, in which the USPSTF recommended against screening for prostate cancer in all men. (Note that the recommendation for men age 70 and older hasn’t changed — the USPSTF still recommends against prostate cancer screening for this age group).
The Science Behind the Update
Dr. Alex Krist, Associate Professor of Family Medicine and Population Health at the Virginia Commonwealth University and active clinician and teacher at the Fairfax Family Practice Residency program, is one of 16 members of the USPSTF. He and his USPSTF colleagues review and evaluate the latest evidence to make evidence-based recommendations for preventive services.
“Since 2012, new evidence has emerged that increases our confidence in the benefits of screening for prostate cancer in men ages 55 to 69,” he says. These benefits, he explains, include reducing the risk of metastatic cancer and reducing the chance of dying from prostate cancer. It also reflects new evidence on the use of active surveillance in men with low- risk prostate cancers. “This tells us that potential benefits and harms of screening are closely balanced,” says Dr. Krist. “That’s how the USPSTF defines a C grade recommendation.”
Potential Benefits, Potential Harms
Prostate cancer screenings measure the level of the prostate-specific antigen (PSA) in men’s blood. “But being screened for prostate cancer is more than agreeing to have blood drawn,” says Krist. “It’s also accepting everything that follows: both the potential benefits and the potential harms.”
On one hand, screening can catch prostate cancer early — which can mean earlier treatment. If 1,000 men ages 55 to 69 are screened, 1 to 2 will avoid death because they get treated earlier.
But on the other hand, screening produces many false positives. That’s because conditions or circumstances other than prostate cancer can raise a man’s PSA level. Out of 1,000 men ages 55 to 69 who get screened, 240 will get a positive result — but only 100 of these men will actually have prostate cancer. For many of these 100 men, their cancer won’t ever grow, spread, or cause problems. And if 80 men who test positive get treatment by having surgery or radiation, 60 or more will experience serious side effects — like urinary incontinence or sexual impotence.
Krist explains that new evidence on the use of active surveillance in men with low-risk prostate cancers is also a relevant factor. “More patients who test positive for prostate cancer are opting for what we call active surveillance instead of surgery or radiation,” he says. “It’s a way of proactively monitoring the cancer instead of actively treating it.”
With active surveillance, patients who have a positive PSA test only have surgery if the prostate cancer begins growing, spreading, or causing harm. This approach reduces the number of unnecessary surgeries and their negative side effects, increasing the odds that the screening will have a net benefit.
A Recommendation for Shared Decision Making
Since so many factors may come into play when choosing whether or not to get screened for prostate cancer, Krist emphasizes that it’s very important for men ages 55 to 69 work with their health care providers to make a decision that’s right for them. “Getting screened may be the right choice for men who are more willing to accept the potential harms,” he says. “While men who are more interested in avoiding those potential harms may choose not to be screened.”
And that’s where shared decision making comes in. Shared decision making encourages providers to inform patients about their options, work with them to identify their values and preferences, and involve them in medical decisions. “Ultimately, our draft recommendation encourages providers and patients to take a shared decision-making approach to prostate cancer screening,” says Krist.
After reviewing the evidence and drafting the recommendation, the USPSTF asked for input from experts, stakeholders, and the public as part of its standard recommendation development process. This public comment period closed on May 8, and the USPSTF is currently in the process of reviewing the results to inform revisions to the draft recommendation statement.
When it comes to prostate cancer screening for men ages 55 to 69, the bottom line is that there’s no one right decision. “But with guidance and support from their providers,” says Krist, “patients can make the one that’s right for them.”