Experts urge medical societies to reconsider prostate cancer screening guidelines
New model estimates demonstrate the long-term benefits of prostate cancer screening and “suggest that the balance of benefits and harms of screening may be more favorable than is generally appreciated,” experts wrote in The New England Journal of Medicine.
“[Prostate-specific antigen] screening has fallen out of favor in recent years for problematic reasons,” Jonathan E. Shoag, MD, assistant professor of urology at University Hospitals Cleveland Medical Center and Case Western Reserve University and an adjunct assistant professor at Weill Cornell Medical College, told Healio Primary Care. “These include misinterpretation of randomized trial results, using short-term data to estimate the benefits of screening, and not taking into account that many prostate cancers present clinically even without screening.”
Currently, the U.S. Preventive Services Task Force recommends that physicians screen men aged 55 to 69 years for prostate cancer on a patient-to-patient basis and that those older than 70 years should not be screened. The American Academy of Family Physicians does not recommend routine screening in men aged 55 years and older, while the American Cancer Society recommends to start screening at age 40 years based on a man’s life expectancy and risk — and only after he has been advised of the “uncertainties, risks and potential benefits” of screening.
According to Shoag, Yaw A. Nyame, MD, MBA, MHSA, urologic oncologist at the University of Washington Medical Center, Jim C. Hu, MD, MPH, urologist at Weill Cornell Medicine, and other members of the research team, there is a widespread misperception that prostate-specific antigen (PSA) screening has “equivocal or no benefit” based on findings of two large, randomized, controlled trials: the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial and the European Randomized Study of Screening for Prostate Cancer (ERSPC) trial. However, the researchers noted that the PLCO trial was not designed to adequately compare the benefits of screening vs. not screening since 90% of the participants in the control group underwent PSA testing.
Meanwhile, results of the ERSPC trial showed that 570 men aged 55 to 69 years would need to undergo screening to prevent one death from prostate cancer. The findings were based on 16 years of follow-up, which researchers wrote “may not provide a sufficient time horizon to examine the mortality benefit from screening because men often begin screening in their 50s and the median age at death from prostate cancer is 80 years.”
The researchers developed a model to further evaluate the long-term effects of prostate-specific antigen (PSA) screening. The model is based on the long-term survival of patients with prostate cancer and competing mortality in the United States. It projected that 11 more prostate cancer cases would need to be diagnosed to prevent one death from prostate cancer over a 25-year period.
“We used conservative assumptions about the benefits of screening, and how much other changes in prostate cancer treatments would impact mortality,” Nyame said in an interview. “We also did not incorporate more recent improvements in screening or treatment via new technologies. In this sense, our model estimates are very conservative and still demonstrate significant benefit to PSA screening over 25 years.”
The researchers told Healio Primary Care that they hope their model prompts medical societies to examine recently published evidence and new techniques in the diagnosis, management and treatment of prostate cancer.
“The ideal scenario would be for professional societies to recognize the long-term downstream benefits of PSA screening in terms of reducing the risk for prostate cancer metastases and death in men with more than a 10-year life expectancy,” Hu said. “In addition, it would be ideal for guidelines from these societies to recognize that not all men who have the PSA test will be subject to biopsy; some men may receive a prostate MRI which, if normal, avoids biopsies for elevated PSA.