Striking the Right Balance With Prostate Cancer Screening

Desai and colleagues,¹ analyzing Surveillance, Epidemiology, and End Results data from 2004 through 2018, found significantly increasing incidence rates of metastatic prostate cancer (mPCa) among men aged 45 to 74 years (during the period 2010-2018) and among men ages 75 and older (during the period 2011-2018). In the earlier periods, incidence rates of mPCa disease were stable in younger men and decreasing in older men. The authors highlighted the temporal association between the mPCa incidence trends and preceding US Preventive Services Task Force (USPSTF) recommendations.

In 2008, the USPSTF recommended against any screening of men aged 75 years and older (grade D), but concluded that evidence was insufficient to make recommendations for younger men (grade I).² PCa incidence rates subsequently began declining, most notably in older men.³ In the fall of 2011, the USPSTF issued a draft recommendation against PCa screening for men of all ages. This grade D recommendation was based on evidence that the PCa mortality benefits of screening were small to none and that screening resulted in harms related to false-positives, biopsy and treatment complications, overdiagnosis, and overtreatment. The final recommendation, published in the spring of 2012, remained a grade D.⁴ The draft USPSTF recommendation was clearly influential, being associated with an astounding reduction in PCa incidence. Jemal and colleagues⁵ estimated that 33 519 fewer US PCas were diagnosed in 2012 compared with 2011. Those authors also presented results from the National Health Interview Surveys showing decreasing PCa screening rates from 2008 to 2013. These findings strongly suggest an association between declining incidence rates and the USPSTF recommendations on screening practices.

Less screening reduces the risks of overdiagnosis and overtreatment, but there is a trade-off. The decreased overall incidence of PCa was followed by a rising incidence of mPCa that Desai and colleagues¹ show had persisted at least through 2018. When prostate-specific antigen testing was first introduced in the early 1990s, the overall incidence rate of PCa, particularly early-stage, markedly increased. An early sign that screening could be effective was a concomitant decline in mPCa, though there was a several-year lag period before mortality declines were observed.³ Analyses of longer-term trends data will be needed to provide the important coda to the 2012 USPSTF guideline story—specifically, whether the changes in screening practices impacted PCa mortality rates. These rates have substantially declined since the early 1990s, but the rising incidence of mPCa could well herald a reversal in mortality trends.

Any observed trends, however, might be transitory because the screening guidelines have again changed. In 2018, the USPSTF withdrew its previous objections to screening and gave a grade C recommendation, advising personalized decision-making, for screening men aged 55 to 69 years.⁶ The USPSTF cited recent clinical trial evidence showing that screening had a greater benefit in reducing PCa mortality than was previously recognized as well as a benefit in preventing metastatic disease. Additionally, observational data demonstrated increased uptake of active surveillance, a strategy of deferring active treatment in the absence of disease progression, among men with low-risk PCas. Overall, they concluded with moderate certainty that there was a small net benefit for screening. This revised guideline should be encouraging clinicians to more consistently address screening with men who are healthy enough to benefit, engaging them in shared decision-making discussions to determine their screening preferences.

Along with the 2018 USPSTF guideline, emerging practice changes around diagnosing and treating PCa might also impact the burden from PCa. The risk of overdiagnosis could decrease because some urological guidelines are now recommending using results from multiparametric magnetic resonance imaging to avoid unnecessary biopsies.⁷ The harms of overtreatment could be mitigated if men with low-risk PCas routinely engage in shared decision-making around treatment choices and are supported in considering active surveillance. Although the overall number of cancer diagnoses might not rebound to the level seen before the guideline change, the number of men discussing screening and receiving diagnoses of clinically important treatable cancers could increase. Achieving these outcomes might further reduce morbidity and mortality from PCa, reversing recent mPCa trends and minimizing the harms of overdiagnosis and overtreatment.

Published: March 14, 2022. doi:10.1001/jamanetworkopen.2022.2174

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Hoffman RM. JAMA Network Open.

Corresponding Author: Richard M. Hoffman, MD, MPH, Department of Internal Medicine, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, 200 Hawkins Dr, SE618 GH, Iowa City, Iowa 52242 (richard-m-hoffman@uiowa.edu).

Conflict of Interest Disclosures: Dr Hoffman reported receiving royalties from UpToDate to write the prostate cancer screening chapter and fees from law firms for serving as an expert witness in prostate cancer screening cases outside the submitted work. No other disclosures were reported.