ESOU18: How Have Recommendations Against Prostate Cancer Screening Impacted the Incidence and Mortality of Prostate Cancer in the US?

Amsterdam, The Netherlands (UroToday.com) The PSA biomarker has had a greater impact on cancer detection staging, prognosis, and monitoring for prostate cancer (PC) than any other biomarker has had on any other cancer! It is more accessible, ubiquitous, quantitative, reproducible, and accurate than any other cancer biomarker. There has been compelling evidence presented for its effectiveness as a screening tool, and its mid-life levels predict lifetime risk of PC metastasis/death with impressive accuracy. Since its first use in the US, it has significantly reduced the incidence of metastatic PC (Figure 1).

The US preventative services task force (USPSTF) was created in 1984 as an independent, volunteer panel of national experts in prevention and evidence based medicine. Its goal is to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling, and preventative medications. In 2017 the USPSTF has given the C and D recommendation for PSA screening of men aged 55-69, and 70 and above, respectively, softening its original recommendation from 2012. The American Urologic Association (AUA) strongly disagrees with the USPSTF’s recommendation and suggests not to screen men aged 40 and below, screen men aged 55 and below only if there is increased risk, for 55-69 – the AUA recommends shared decision making based on patients’ values and preferences, and no screening is recommended for men aged 70 and above, or those with less than 10-15 years of life expectancy. Studies have shown that across the US PC screening has gone down since the original USPSTF recommendation in 2012 (Figure 2).

Most urologic organizations agree that there is little or no benefit in PSA screening among men aged 75 and above, or in men with 10-15 year life expectancy. Additionally, it is known that screening can be harmful in can result in over-diagnosing indolent disease, leading to over-treatment. Those considering screening should have an informed discussion with their provider. 

It is known that PSA has resulted in age adjusted mortality decreasing over the last 20 years by 45%. Furthermore, countries without prevalent PSA testing have failed to show comparable outcomes. Properly performed randomized screening trials have shown a 21-44% mortality reduction resulting from PSA screening, with a number needed to screen, with intermediate follow-up, being at 293 per death avoided. Additionally, the number needed to treat is 12.

Dr. Evans concluded his talk by stating that the latest USPSTF recommendations, have caused a decrease in PC testing, incidence and localized disease, and there is an evident rise in metastatic disease. The most current data support selective, informed testing.

Figure 1:
PSAscreen1

Figure 2:
PSAscreen2


Speaker: Christopher Evans, MD, FACS, Chair, Department of Urology, Professor, UC Davis, Sacramento, California, US

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at The 15th Meeting of the EAU Section of Oncological Urology ESOU18 - January 26-28, 2018 - Amsterdam, The Netherlands
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