New draft guidelines from the U.S. Preventive Services Task Force (USPSTF), a panel of experts who issue non-binding health recommendations, state that men between the ages of 55 and 69 should make the decision about whether or not to be screened for prostate cancer in consultation with their healthcare practitioner. This screening recommendation applies to men who have not had a previous diagnosis of prostate cancer and have no signs or symptoms of the disease. Previous recommendations, issued five years ago, advised against routine screening for prostate cancer.
The blood test used to screen for prostate cancer, called the prostate specific antigen (PSA), has long been controversial. It can detect an increase in PSA, a protein produced primarily by cells in the prostate. While PSA increases may be an indication of prostate cancer, an elevated result can also signal an enlarged or inflamed prostate not caused by cancer.
In addition, even when an elevated PSA is caused by cancer, healthcare practitioners cannot be sure whether the cancer will spread and become life-threatening or never pose a serious health risk. Because healthcare practitioners cannot clearly differentiate between these two situations, some men may opt to be treated with surgery, as well as with radiation and chemotherapy—potentially adding side effects that might not have been necessary.
The Task Force based its updated guidelines on a review of new evidence released since the last recommendation, which includes data from the European Randomized Study of Screening for Prostate Cancer (ERSPC). The new evidence showed that for men ages 55 to 69, the potential harms and benefits from screening are about equal, so the decision to screen should be an individual one. The recommendation applies to men of average risk as well as men with risk factors. However, those at increased risk, such as African American men and men who have a family history of prostate cancer, should receive additional information about their risk to aid their decision about screening, according to the Task Force. The currently available evidence showed no benefit to PSA screening for men 70 and older.
"Prostate cancer is one of the most common cancers to affect men, and the decision about whether to begin screening using PSA-based testing is complex. For men who are more willing to accept the potential harms, screening may be the right choice for them. Men who are more interested in avoiding the potential harms may choose not to be screened," says Alex H. Krist, M.D., M.P.H., an associate professor of family medicine and population health at Virginia Commonwealth University and a member of the Task Force. "In the end," says Dr. Krist, "men who are considering screening deserve to be aware of what the science says, so they can make the best choice for themselves, together with their doctor."
The draft recommendation is also based in part on new evidence on the use of "watchful waiting" or "active surveillance" instead of immediately treating prostate cancer. Watchful waiting may include occasional PSA tests to monitor the cancer while active surveillance includes regular, repeated PSA tests (about every six months) as well as repeated digital rectal exams and prostate biopsies (about every 12 months) to help assess the cancer. According to the Task Force, in recent years active surveillance has become more common and could reduce risk of side effects from over-treatment.
The new draft guidelines from the USPSTF are more in line with those from some other major medical organizations, though some specifics vary. For example, the American Urological Association recommends shared decision-making by healthcare practitioners and their patients ages 55 to 69 with a life expectancy of more than 10 to 15 years. The American Cancer Society advises that patients and healthcare practitioners begin discussing the benefits and risks of screening when the patient turns 50, or younger if the man is at high risk. Though the American Academy of Family Physicians advises against screening, the recommendation is currently under review.
Generally, most health organizations agree that men should receive balanced information about prostate cancer screening so they know the risks, uncertainties, benefits, and limits of prostate cancer screening and treatment. They should work with their healthcare practitioners to understand their options and decide what is best for themselves.
The draft guidelines were open for public comment through May 8th, 2017 and the Task Force is expected to issue its final recommendation later this year.