Curious Dr. George | Plumbing the Core and Nibbling at the Margins of Cancer

Big 2017 Change on PSA by USPSTF

Marc B Garnick, MD, Editor in Chief, HMS Annual Report on Prostate Diseases; Gorman Professor of Medicine, Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, MA . E. David Crawford, MD, Professor of Urology and Radiation Oncology at The University of Colorado, Anschutz Campus, Aurora, CO; Medical Advisor and Founder, 3DBiopsy, Inc., Aurora, CO

Q: The new draft USPSTF recommendations for rapid comment on use of PSA for screening represent a big change from 2012. They now read: “The decision about whether to be screened for prostate cancer should be an individual one. The USPSTF recommends that clinicians inform men ages 55 to 69 years about the potential benefits and harms of prostate-specific antigen (PSA)–based screening for prostate cancer” and much more. Shared patient-physician decision making. What do you think?

A: The long awaited updated recommendations from the United States Preventive Services Task Force, issued at their traditional 5-year interval, got it right–Again! While the 2012 “D” recommendation from the Task Force was met with great skepticism and animosity from several groups, the change in the 2017 recommendation now emphasizes the importance of the Task Force’s continuing evaluations of new and more mature data.
In a series of four detailed, analytic and erudite publications that provide the underpinnings for their new recommendations, even the most serious students of prostate cancer and prostate cancer screening–ourselves included–can appreciate the enormous task that members of the Task Force and its sub-sections undertook. The result not only justifies the correct C recommendation for those men between ages of 55 and 69 and the unchanged D recommendation for those above 70. Moreover, the recommendation calling for the serious need for more study about the complexities facing men who are at increased risk for prostate cancer– African-American and those with a significant family history–should serve as a call to action for research agencies whose worldwide populations are affected by this common cancer. The complexities of prostate cancer biology are outlined in these accompanying publications and will undoubtedly provide avenues for productive future research programs.
The changes in the Task Force’s recommendations appropriately relied heavily on several key studies- among them, the PLCO, ERSPC and ProtecT. Of the key factors that have become available since issuance of the 2012 “D” guidelines were both the increasing utilization of active surveillance–to help address the issue of over-diagnosis and the harms of overtreatment–and the potential that the development of metastases could be decreased by treatment compared to active maintenance. This latter assessment emanated from the UK ProtecT study and its context must appreciate that many of the patients enrolled in that study who received no active treatment had cancer characteristics such as high Gleason scores that would generally have prompted interventions here in the United States.
In the end, the Task Force has in fact provided a strong rationale for what is commonly happening in practice today despite the universal 2012 “D” recommendations. Patients should consider shared decision making with their health provider about the harms and benefits of undergoing screening, and treatment if a cancer is found, and that values and preferences of the individual patient should play an important role. But, today, as was the case in 2012, the ability to show an overall survival benefit from any screening recommendation still eludes us and the cancer-specific survival benefit, if one exists at all, is at best, very modest. Hopefully, these updated screening guidelines will encourage meaningful research to enable real advances at the patient level to be achieved.
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