Prostate Cancer: to screen or not, and when to screen?
John came in for his regular annual check up. He is 75 years old, is on medications for his heart disease, has COPD, and was hospitalized twice last winter for pneumonia. He had to go to a rehabilitation center to get better. He had blood work for this visit, to check his kidneys, his cholesterol and his liver tests. Should he have a PSA to screen for Prostate Cancer? The US Preventive Services Task Force came out with recommendations to limit the screening of elderly males with life expectancies of less than 9 years. At the Annual Oncology meeting, these data were presented, following the impact of those recommendations.
National Prostate Cancer Screening Rates After the 2012 US Preventive Services Task Force Recommendation Discouraging Prostate-Specific Antigen–Based Screening Michael W. Drazer, Dezheng Huo and Scott E. Eggener
⇑+Author Affiliations All authors: University of Chicago Medical Center, Chicago, IL, Corresponding author: Scott E. Eggener, MD, 5841 South Maryland, Mail Code 6038, University of Chicago Medical Center, Chicago, IL 60637; e-mail: seggener@surgery.bsd.uchicago.edu. Presented at the 51st Annual Meeting of the American Society of Clinical Oncology, Chicago, IL, May 29-June 2, 2015.
This study examines the effect on screening rates after the recommendations of the US Preventive Services Task Force (USPSTF). It shows that Prostate cancer screening significantly declined among men age 50 years and older in the United States after the 2012 USPSTF recommendation discouraging PSA-based screening. Despite these declines, in 2013 approximately one third of men age 65 years and older with a high risk (52%) of predicted 9-year mortality were screened—approximately 1.4 million men.
Although rates of screening have declined, suggesting more physicians are adhering to the guidelines in 2012 than in 2008, but there still remain high levels of screening in men more than 75 years of age, with limited life expectancy. More needs to be done to increase awareness in patients and physicians regarding the over diagnosis and over treatment of these men.
These may include increasing awareness of initiatives such as Choosing Wisely recommendations from the American Society of Clinical Oncology and recommendations from the American Geriatrics Society, both of which discourage screening men with limited remaining life expectancies.
However, these measurements need to take into account the pressure of yardsticks satisfying meaningful use, which are measuring the care provided by primary care physicians, and the need to come up with new parameters to measure for each interval.
There is pressure to satisfy the urge to screen, and patients at low risk for prostate cancer may be monitored with extended screening intervals, an approach reinforced by data from the European Randomized Study of Screening for Prostate Cancer, the newest American Urological Association recommendation, and other previously published studies.2,24,37,38 .
The authors of this study note that “modeling studies from the Rotterdam component of the European Randomized Study of Screening for Prostate Cancer showed that annual screening of men age 55 to 67 years results in an over diagnosis rate of 50%.39 Heijnsdijk et al40 demonstrated that greatest cost-effectiveness was achieved with a screening program offered to patients between age 55 and 60 years with 1- to 2-year intervals. Gulati et al37 showed that men with PSA values less than the median age group–matched levels may be screened up to every 5 years without dramatically impacting patient-centered outcomes. This approach would reduce over diagnoses by approximately 27% and false-positive results by 50%, yet would still save 83% of lives compared with an annual screening interval approach. A prospective study by Aus et al38 similarly demonstrated that men age 50 to 66 years with low baseline serum PSA levels could be safely screened every 3 years with minimal effects on prostate cancer–specific mortality.”
If a high PSA is noted, it should not automatically trigger a biopsy. The probability of high-risk cancer should be estimated using existing validated risk calculators.41–45 New biomarkers may improve on PSA alone in predicting the likelihood of a man harboring a high-grade cancer. Tests such as the prostate CA 3, kallikrein panel, and Prostate Health Index have superior operating characteristics compared with PSA alone.46–48 The adoption and integration of these tests, require further study.
This study does demonstrate a nationwide decline in national prostate cancer screening rates among men age 50 years and older after the 2012 USPSTF guideline discouraging PSA testing for the early detection of prostate cancer. However, in spite of overall improved trends, roughly a third of men older than age 65 years with a high probability (> 52%) of death within the next 9 years were screened for prostate cancer, exposing these approximately 1.4 million men to a high risk of over diagnosis and overtreatment.
To screen for Prostate Cancer continues to be an evolution in thinking, at the patient and physician level. After discussing this information with John, he and his physician decided against a routine screening PSA.