The United States Preventive Services Task Force (USPSTF) has updated their recommendation on PSA screening in men age 55-69 to a “C” grade, as reported in the recent edition of JAMA. The recommendation suggests an individualized approach to PSA testing with discussion of potential benefits and harms of screening by patient and physician.
This report is the culmination of years of analysis and re-analysis, argument and counter-argument regarding PSA testing in the US. The initial “D” grade recommendations by the USPSTF in 2008 for men over age 70, and in 2012 for PSA testing overall were met with considerable controversy. There were passionate pleas from both sides; one side argued that the available data from two randomized trials proved that PSA testing led to more harm than benefit, while the other argued that the available data from these trials was significantly flawed and/or reported too early to actually detect a significant difference in survival.
Subsequent analysis of the U.S.-based trial has shown significant contamination of the control group1, and long term follow-up of the European trial has shown a steadily decreasing number needed to screen to save a life and decreasing risk of metastasis2. Additionally, testimony from prostate cancer survivors and advocacy groups was presented, as well as data showing that decreased PSA testing has led to fewer diagnoses of intermediate and high grade cancer which may lead to an increase in locally aggressive or metastatic disease in the coming years3.
In light of the continuing controversy, the USPSTF revisited the PSA screening guidelines and gave opportunity for open commentary.4 The new recommendation has been well-received in the urologic and oncology communities, and provides a framework for primary care physicians to have meaningful shared decision making regarding screening among appropriate men.
The Task Force also gave particular attention to known high-risk populations such as black men and men with a family history of prostate cancer, which is a welcome change. Treating physicians must continue to recommend appropriate treatment to men diagnosed with prostate cancer, favoring active surveillance for men with low-grade disease, and minimizing morbidity during aggressive treatment for intermediate and high risk disease. The increasing utilization of serum and urine-based biomarker tests serves as an adjunct to PSA testing and biopsy and assists in more precise risk stratification. It remains to be seen if the update in the USPSTF recommendation will make a significant change in PSA testing by primary care physicians, but the new guideline provides men the opportunity for more control over their health care decisions.
- Shoag, J. E., Mittal, S., Hu, J. C.: Reevaluating PSA Testing Rates in the PLCO Trial. N Engl J Med, 374: 1795, 2016
- Schroder, F. H., Hugosson, J., Roobol, M. J. et al.: Screening and prostate cancer mortality: results of the European Randomised Study of Screening for Prostate Cancer (ERSPC) at 13 years of follow-up. Lancet, 384: 2027, 2014
- Barocas, D. A., Mallin, K., Graves, A. J. et al.: Effect of the USPSTF Grade D Recommendation against Screening for Prostate Cancer on Incident Prostate Cancer Diagnoses in the United States. J Urol, 194: 1587, 2015
- Bibbins-Domingo, K., Grossman, D. C., Curry, S. J.: The US Preventive Services Task Force 2017 Draft Recommendation Statement on Screening for Prostate Cancer: An Invitation to Review and Comment. JAMA, 317: 1949, 2017