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July 2018

Implications of the New USPSTF Prostate Cancer Screening Recommendation—Attaining Equipoise

Author Affiliations
  • 1Cancer Epidemiology and Population Science Program, Holden Comprehensive Cancer Center, Department of Medicine, University of Iowa Carver College of Medicine, Iowa City
JAMA Intern Med. 2018;178(7):889-891. doi:10.1001/jamainternmed.2018.1982

In abandoning its 2012 objection to prostate-specific antigen (PSA)–based screening for prostate cancer (D recommendation),1 the US Preventive Services Task Force (USPSTF) now supports individualized decision making for men aged 55 to 69 years (C recommendation).2 The new Task Force recommendation, supported by an evidence report and systematic review,3 now aligns the USPSTF with the American Cancer Society4 and the American Urological Association.5 The USPSTF recommendations, which have consistently been evidence based, appear to have a large influence on practice patterns. Following the 2008 recommendation against screening men older than 75 years,6 prostate cancer screening and cancer incidence rates markedly declined for older men.7 In the year following the 2011 release of a draft recommendation against any screening (D recommendation; final version published in May 20121), the number of men diagnosed with prostate cancer decreased by over 33 000.7 Prostate cancer screening rates also subsequently decreased among all age groups by 2013.7 The new C recommendation2 may well be associated with a resurgence in prostate cancer screening and increased numbers of prostate cancer cases diagnosed, especially if the new guidelines are misunderstood to be endorsing screening rather than offering a more nuanced message about decision making.

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2 Comments for this article
Prostate cancer mortality has dropped 30%
Richard Cooper, MD | Loyola University Medical School
I find it odd in these commentaries and editorials that the public health outcome is often not mentioned. Whatever the reasons - screening vs better therapy - the overall mortality from prostate cancer began to fall in the mid-'90's and is now down substantially. I assume it is a combination of both modalities, but the marked reduction in the number of patients who present with advanced disease suggests a substantial benefit for screening. In the end, population outcomes are the final arbiter and the prostate cancer story has much to recommend it. I think it further suggests the limitations of trials when a practice - like PSA screening - has already been widely adopted.
How many quality-adjusted life years were lost due to the 6 years of USPSTF opposition to PSA screening?
DAVID KELLER, MS, MD | Retired Internist
PSA screening has never been given a fair testing in the controlled trials.

In real practice, false positives are reduced by simply repeating an elevated PSA test a week or two later, after transient spikes in PSA caused by trauma, infection, too much sex, too little sex, or other factors have resolved. If the PSA comes back down to the patient's baseline level, it was not cancer. Only a foolish internist would refer a patient for prostate biopsy based on an isolated elevated PSA, as the study protocols dictated.

In real practice, PSA
velocity is taken into account. Only a foolish internist would send a patient to biopsy for a rise in PSA from 2.9 to 3.1 ng/dl, over one year, as the study protocols dictated (for a static biopsy threshold of 3.0). Likewise, a patient whose PSA rose from 0.5 to 1.8 ng/dl in one year (confirmed) should have been sent for biopsy, even though his PSA never got near the biopsy static threshold. The reason is that PSA velocity is a more accurate marker for malignancy than is static PSA, which cannot distinguish between benign hyperplasia versus malignancy as its source.