In today’s International Prostate Forum at the 2016 AUA, Dr. Matt Cooperberg discussed the impact of the USPSTF Grade D recommendation on screening and staging. Along with rising incidence, there has been a 50% drop in age adjusted prostate cancer mortality since the early 1990s. Worldwide, there were 258,000 deaths in 2008, and this number has increased to 300,000 deaths this year.
Meanwhile, the expected rate of US incidence is down to 180,000 this year. While this still makes prostate cancer the most common cancer among men, this represents a decline in incidence and is likely attributable to the USPSTF Grade D Recommendation.
We know, based on data from ERSPC that there is a 21-29% relative reduction in prostate cancer morality (42% in Goteborg). We also know that PLCO is non-informative with respect to the question of screening vs no-screening as there was approximately 90% contamination in the control arm of PLCO, and that men in the control arm actually had more PSA tests than those in the intervention arm. This data should be disregarded from meta-analyses and policy recommendations. The grade D recommendation misrepresents the evidence on screening as it includes too short of a time-horizon; with a longer time horizon, the ratio of overdiagnoses: lives saved decreases 7-fold. However, in the purview of public health, the issue of over-diagnosis and over-treatment remains of ultimate importance and may have driven the decision; it’s ultimately largely our fault.
Meanwhile we have made recent strides in improving our risk stratification for determination of who should receive treatment. Review of UCSF data shows a utilization rate of AS of 40% for low risk men, up from a historic rate of 10%. Early data from AQUA shows similarly encouraging results.
Study of PCP behavior with respect to PSA screening demonstrates no change between 2000 and 2005, as men in their 50s were under-screened and men in their 70s were over-screened. Similar trends are seen when comparing screening rates for 2005 and 2010. However, it appears that the vast majority (69%) of PCPs consider the USPSTF over ACS, AUA, and ACS guidelines. Barocas and colleagues demonstrated that the diagnosis count has decreased on a monthly basis and continues to decline since the release of the grade D recommendation.
While we are over-diagnosing fewer low risk men, we are also under-diagnosing high risk disease. If we were to stop screening altogether, we would be back to where we were in the 1980s in terms of patients presenting with locally advanced and metastatic disease.
In conclusion, the USPSTF analysis downplayed benefits, overstated harms, and was predicated on too short of a time horizon. Overtreatment is certainly an issue, but this may have been traded for under-treatment, which represents a potentially more dangerous public health crisis. The answers lie in smarter screening and better treatment decisions. Finally, Dr. Cooperberg encouraged ownership of the data to promote ownership of the truth.
Presented By: Matt Cooperberg , MD