USPSTF Panel Announces Final Recommendation Against PSA Screening for Prostate Cancer
May 24, 2012 -- The United States Preventative Services Task Force (USPSTF) made a final recommendation on May 21, 2012 against prostate-specific antigen (PSA) based screening for healthy men, asserting that there is “moderate or high certainty that the service has no benefit or that the harms outweigh the benefits.”
The task force discouraged the use of the test by issuing it a Grade D rating. The D rating applies to men of all ages but does not apply to the use of PSA testing for monitoring patients after a prostate cancer diagnosis or treatment. The USPSTF final recommendation is consistent with its draft recommendation announced on October 7, 2011. The USPSTF provided a prostate cancer specific fact sheet to PCF.
Additionally, the USPSTF says there is little, if any, evidence that PSA testing saves lives and that too many men instead suffer from impotence, incontinence, heart attacks and occasionally death from treatment of tiny tumors that would never kill them.
A dissenting opinion was published in the Annals of Internal Medicine by some of the leading clinical scholars in prostate cancer care, including PCF-research award winners Dr. William Catalona and Dr. Patrick C. Walsh. These experts believe the USPSTF overestimated the harms and underestimated the benefits of PSA screening in the United States.
The Prostate Cancer Foundation responded to the USPSTF draft recommendation and today remains consistent in the belief that PSA screening still plays an important role in detecting early prostate cancer in informed patients, though better guidelines are needed.
The Prostate Cancer Foundation:
- Supports continued routine PSA screening of informed patients until new American Urological Association clinical guidelines on PSA screening are issued and disseminated.
- Supports a patient’s choice to have a PSA test. The decision should be made between a man and his personal physician based on his individual status with respect to age, symptoms, family history or concerns about prostate cancer.
- Supports American Cancer Society communications calling for far better processes of informed patient decision-making both prior to, and after, PSA screening in healthy men.
- Opposes the elimination of reimbursement for an informed patient requesting screening.
- Strongly recommends intensified National Cancer Institute focus and research investment in better early detection tests of lethal prostate cancers. We also recommend new public-private research partnerships drawn from substantially increased and coordinated research investments from the American Cancer Society (ACS) and the American Urologic Association (AUA) partnering with the NCI and PCF. Such public-private partnerships will accelerate the discovery, testing, and validation in U.S. men of new biotechnologies for lethal cancer detection that are superior to PSA screening.
- Calls for greater patient participation in clinical studies evaluating new genomics-based prostate cancer detection tests.
- Calls for greater eligible patient participation in and physician referral of patients to ongoing new clinical trials evaluating Proactive Surveillance (watchful waiting).
The folllowing text is from the Prostate Cancer Foundation's initial media release.
The USPSTF has heightened awareness with new data of the issue of severe complications and patient suffering from the overdiagnosis and overtreatment of indolent prostate cancers. In addition to the emotional and physical suffering experienced by men and their families, a recent cost-effectiveness analysis of PSA screening estimated that the cost of diagnosis and treatment is over $5,227,306 per patient to prevent one U.S. prostate cancer death.
The USPSTF’s position provides a teachable and actionable moment for the medical community to improve targeting of PSA screening in patients, reduce over-testing and improve processes of patient education on the risks of overtreatment from PSA screening.
In the abstract, "task force" recommendations can create patient confusion and may result in unquantifiable numbers of men who will get a delayed diagnosis of a lethal and curable cancer. However, it should be noted that the recommendation clearly states, “…while the USPSTF discourages the use of screening tests for which the benefits do not outweigh the harms in the target population, it recognizes the common use of PSA screening in practice today and understands that some men will continue to request and some physicians will continue to offer screening. An individual man may choose to be screened because he places a higher value on the possibility of benefit, however small, than the known harms that accompany screening and treatment of screen-detected cancer, particularly the harms of over diagnosis and overtreatment. This decision should be an informed decision, preferably made in consultation with a regular care provider. No man should be screened without his understanding and consent; community-based and employer-based screening that does not allow an informed choice should be discontinued.”
PCF is encouraged that the AUA has convened a panel of medical experts who work routinely with prostate cancer patients, to improve guidelines for more targeted use of the PSA test as a screening tool.
Moving Past the PSA Debate
The PSA test still has a role to play in early detection and treatment for millions of men. It should be noted that in the pre-PSA era, approximately 80% of patients who were diagnosed with prostate cancer, were already in advanced stages of the disease with metastatic cancer. Today, the number of patients who are diagnosed with metastatic disease at time of initial diagnosis is around 20%. In the past 15 years, the death rate has been reduced from 42,000 annually to 33,000.
The PSA debate can become moot with intensive and accelerated research that delivers a better test. For more than a decade, PCF has been supporting research to find new and better molecular biomarkers for prostate cancer. At PCF’s 2011 Scientific Retreat, data on 17 new biotechnologies that complement or have the potential to replace PSA screening was presented. Many of these biotechnologies have the potential to discern between indolent and lethal prostate cancers. Essential will be patient participation in clinical trials to evaluate these new tests. New data on urine and blood tests using genetic biomarkers also offer the promise of eliminating a large number of unneeded biopsies and subsequent unnecessary treatment.
Given the enormity of the problem of overdiagnosis and overtreatment, PCF is also supporting a $5 million research project, the National Proactive Surveillance Network, to determine which patients can be maintained on proactive surveillance and which patients need to be recommended for surgery or radiation. Additional clinical trials of proactive surveillance are urgently needed to develop guidelines for men whose cancer is not life-threatening.
Read more about the USPSTF recommendation at www.pcf.org/uspstf
For scientific background and references, please click here.