Prostate cancer screening: the decision is up to you

[May 09, 2018] By Will Boggs MD

(Reuters Health) - Men aged 55 to 69 years should be informed of the possible benefits and harms of prostate cancer screening and then make their own decision on whether or not to be screened, according to the latest recommendations from the U.S. Preventive Services Task Force (USPSTF).

"Based on the latest scientific evidence, the Task Force hopes that men ages 55 to 69 who are considering prostate cancer screening and their doctors will have an open conversation about the benefits and harms of screening, so men can choose whether screening is right for them," Dr. Alex Krist, USPSTF vice chair from Virginia Commonwealth University in Richmond, told Reuters Health in an email.

A man's lifetime risk of being diagnosed with prostate cancer is about 13 percent, but the lifetime risk of dying of prostate cancer is only 2.5 percent, with half of those deaths occurring at age 80 or beyond, the Task Force authors note in their recommendation statement published on Tuesday in JAMA.

According to results of clinical studies, prostate cancer screening with the PSA (prostate-specific antigen) blood test could prevent approximately 1.3 deaths from prostate cancer over 13 years per 1,000 men screened. It might also prevent 3 cases of prostate cancer that has already spread per 1,000 men screened.

But there is no evidence that prostate cancer screening improves overall survival.

And there can be downsides of screening, including false-positive results that require additional testing and prostate biopsy, overdiagnosis and overtreatment, and treatment complications like incontinence and impotence.

Based on this information, the USPSTF recommends that men between the ages of 55 and 69 be provided this information and that their doctors not screen men who don't express a preference for screening.

For men aged 70 years and older, USPSTF discourages prostate cancer screening, because it has shown no benefit on prostate cancer-related death rates in this age group.

For two groups of men known to have a higher risk of prostate cancer - African American men and men with prostate cancer in their family - there isn't enough information to make a firm recommendation about screening, so USPSTF strongly encourages additional research to identify the best strategy for these men.

"While we know that African American men and men with a family history are more likely to get prostate cancer and more likely to die from prostate cancer, we don't know if screening offers them any greater benefit," Krist said. "Men at higher risk for prostate cancer should talk about this with their doctor when considering whether to be screened, but they should also weigh the potential benefits and harms when deciding whether screening is right for them."

It's important for all men to be informed, because existing guidelines have slightly different recommendations. The American Academy of Family Physicians and the Canadian Task Force on Preventive Health Care recommend against PSA-based screening for prostate cancer, while the American College of Physicians, the American Urological Association and the American Cancer Society recommend shared decisionmaking but differ in certain details from one another and the USPSTF recommendations.

"Different men will weigh the potential benefits and harms differently, so the most important thing for them to do is talk with their doctor - armed with the research and guidance provided by our recommendation - so that they can make an informed decision based on their values and individual situation," Krist said.

A JAMA patient page with background on prostate cancer and a summary of the new recommendation is available on the journal's website (https://bit.ly/2jF4Wuq).

"We think that the important part of this recommendation, which should be stressed, is that we should let each man decide himself, based on his own perception of the risks and benefits, whether he wants to be screened," said Dr. Danny Vespini and genetic counselor Justin Lorentz, who run the Male Oncology Research & Education Program at the University of Toronto and were not involved in the USPSTF guidelines.

"Men with a family history of prostate cancer, who are West African or Caribbean ancestry, or who have an inherited gene mutation that predisposes them to prostate cancer, should be told that the recommendations do not fully apply to them, and they definitely should talk to their doctor about prostate cancer screening if they aren't already having it done," they said in an email.

"Our group and many others are actively doing research in identifying biomarkers of aggressive disease in the active surveillance population, so that someday men diagnosed with early disease that does not pose any threat to their lives can avoid unnecessary and morbid therapies," they added.

SOURCE: https://bit.ly/2KGOZjD JAMA, online May 8, 2018.

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