The US Preventive Services Task Force recently released a draft statement with updated advice for the use of Prostate Specific Antigen (PSA) in screening for prostate cancer.  They will be accepting public feedback regarding their recommendations until May 8, 2017, after which time a final recommendation will be released.

Back in 2012, the USPSTF unequivocally told doctors to discourage patients from getting PSA testing.  They stated that the risks of false positives and overtreatment outweighed the benefits.  But after much debate, the USPSTF has backed off that advice. 

 

Here is the upshot of their updated recommendations from https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementDraft/prostate-cancer-screening1

 

▪   PSA tests for men age 70 and older and men under age 55 are still discouraged

▪   For men between 55 and 69, the panel is punting the decision to doctors. 

“The decision about whether to be screened for prostate cancer should be an individual one. Screening offers a small potential benefit of reducing the chance of dying of prostate cancer. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and impotence. The USPSTF recommends individualized decision making about screening for prostate cancer after discussion with a clinician, so that each man has an opportunity to understand the potential benefits and harms of screening and to incorporate his values and preferences into his decision.” 

▪   The task force backed down on its earlier advice in light of new evidence. Back in 2012, the best evidence suggested that for every 1,000 men screened, 0.8 prostate cancer deaths would be prevented in the next 10 to 15 years. But a longer look at the participants in prostate cancer studies has raised that to 1.3 deaths prevented in the same time frame.  Additionally, studies have since reported that screening 1,000 men ages 55 to 69 years may prevent approximately 3 men from developing metastatic prostate cancer.

▪   The panel also took into consideration that how men seek treatment has shifted. More men now who receive cancer diagnoses are opting for active surveillance — watching their cancer closely — rather than treatment. That lessens the potential harms, such as impotence and incontinence after surgery; compared to the last time the task force evaluated the screenings.

More detailed information is in CaSfA's April 18, 2017 newsletter.  Join CaSfA to receive our newsletters!!

 

An important study looking at the treatment of early stage prostate cancer was published in the New England Journal of Medicine on Wednesday (http://www.nejm.org/doi/full/10.1056/NEJMoa1606220?query=featured_home#t=articleBackground ).   The use of prostate-specific antigen (PSA) testing has dramatically increased the diagnosis of prostate cancer.  Close to 181,000 cases of prostate cancer will be diagnosed in the US in 2016 and over 26,000 men will die of the disease.  But many cases of this cancer will progress slowly and not lead to death.  Studies have been trying to determine if some men can safely avoid radical treatments and their associated side effects and complications. This study looked at 3 different treatment approaches to men diagnosed with early prostate cancer:  surgery (radical prostatectomy), radiotherapy and active monitoring/surveillance.

 

Here are the basics of the study:

·      The study recruited men 50-69 years old in the UK

·      1643 men were diagnosed with localized prostate cancer and agreed to be in the study

·      The men were followed for a median of 10 years

·      The study looked at prostate-cancer mortality (deaths that were definitely or probably due to prostate cancer or its treatment) at a median of 10 years follow up.  It found that death from prostate cancer remained low, at approximately 1%, irrespective of the treatment assigned.

·      Of the 545 men assigned to the active monitoring/surveillance treatment arm, 291 men required intervention during the study (56 within 9 months of starting the study).  142 (49%) underwent surgery; 97 (33%) received radiotherapy according to the study protocol.  The rest received non-protocol radiotherapy, brachytherapy (insertion of radioactive pellets into the prostate), or other treatment.

·      The study also looked at mortality from all causes, rates of metastases, clinical progression of cancer, treatment failure and treatment complications.

·      There was no difference in mortality from all causes between the three treatment groups

·      204 men had disease progression, including metastases.  The incidence was highest in the active monitoring/surveillance group (112 men vs. 46 in the surgery group and 46 in the radiotherapy group).

·      There were no deaths attributable to surgery, but 9 men had blood clots/cardiovascular complications; 14 required multiple blood transfusions for blood loss; 1 had rectal injury; 9 had anastomotic problems (leakage of urine into the body from a damaged ureter).

·      One limitation of the study was a protocol that was developed almost 20 yrs ago (treatments and diagnostic techniques have evolved since then).  Also the men will need to be followed for a longer period of time to determine if any difference in survival rates will emerge.

The study authors conclude:  “At a median follow-up of 10 years, the ProtecT trial showed that mortality from prostate cancer was low, irrespective of treatment assignment. Prostatectomy and radiotherapy were associated with lower rates of disease progression than active monitoring; however, 44% of the patients who were assigned to active monitoring did not receive radical treatment and avoided side effects. Men with newly diagnosed, localized prostate cancer need to consider the critical trade-off between the short-term and long-term effects of radical treatments on urinary, bowel, and sexual function and the higher risks of disease progression with active monitoring, as well as the effects of each of these options on quality of life. Further follow-up of the ProtecT participants with longer-term survival data will be crucial to evaluate this trade-off in order to fully inform decision making for physicians and patients considering PSA testing and treatment options for clinically localized prostate cancer.”

I attended the Annual Massachusetts Prostate Cancer Symposium on Friday, May 17.  I listened to some great lectures.  Especially interesting were the talks about PSA (prostate-specific antigen) testing.  This blood test started being used in the mid 1990's.  Since it's use began, we have seen a doubling in the rate of prostate cancer, but not much change in the number of men dying from the disease.

Many have taken a closer look at the PSA screening test and prostate cancer as a whole.  It has been discovered that many cases of prostate cancer follow a slowly progressive course and men may even remain asymptomatic throughout their lifetime.  For these men, the complications from treatment of prostate cancer outweigh any benefit of treatment.

So, last year the US Preventative Services Task Force released this recommendation:  "The reduction in prostate cancer mortality 10 to 14 years after PSA-based screening is, at most, very small, even for men in the optimal age range of 55 to 69 years.  The harms of screening include pain, fever, bleeding, infection, and transient urinary difficulties associated with prostate

biopsy, psychological harm of false-positive test results, and overdiagnosis.

Harms of treatment include erectile dysfunction, urinary incontinence, bowel dysfunction, and a small risk for premature death. Because of the current inability to reliably distinguish tumors that will remain indolent from those destined to be lethal, many men are being subjected to the harms of treatment for prostate cancer that will never become symptomatic. The benefits of PSA-based screening for prostate cancer do not outweigh the harms."

We need to determine which men are a risk for aggressive prostate cancer because these are the men who are dying from this cancer.  We do know there are certain genetic mutations which are important (BRCA for example).  Men who have any relatives with prostate cancer may choose to have a PSA test, or one of the newer (PCA-3) urinary screens.

All men need to have a discussion with their physicians to determine their individual risk for prostate cancer and whether screening will be of benefit.