He then went into recent data regarding incidence and mortality. Interestingly, in the past few years, since the introduction of the new recommendations in 2012, the incidence of prostate cancer has been in decline – at levels similar to the 1980’s, before PSA screening. Over the same time frame, PCa mortality had been dropping since the advent of PSA screening – until this year. This was the first year, there was no decline in PCa mortality!
The 2012 statement read: Do Not Use PSA Screening for prostate cancer. Grade D recommendation. The issue was that no urologist was part of the decision. Unfortunately, while the members of the panel did list exceptions in the fine print, most primary care physicians do look to this for guideline management. As such, it had an immediate effect on prostate cancer screening and incidence…. Even at a monthly level. The decline has been ongoing. The rate of both high and low risk PCa has been decreasing similarly.
The concern is that this would lead to levels of metastatic prostate cancer seen prior to PSA screening. As Dr. Cooperberg noted, the rates of mPCa had been rising even before the recommendation came out. Unclear why this was happening – but even more reason to not revert back to non-PSA screening days.
The lack of involvement from the oncologists involved in prostate cancer management (urology, radiology, medical oncology) contributed to this. However, we, as a field, have never been good in translating the screening message to the primary care physician.
Due to improper screening age range and improper treatment over the past 10-20 years, we have also hurt ourselves. We often over treat low-risk disease and under treat high-risk disease.
He did review in brief the 3 prostate cancer screening studies – EORTC, Goteburg, and PLCO – along with their major findings and flaws. The EORTC and Goteburg (best run of the 3) showed relative reduction in prostate cancer mortality. The PLCO study was noninformative to address the question (contamination in the non-screening arm).
Bottom Line 2017:
o Screening 1-4 years starting age 55-70 results in at least 30% RR of PCa Mortality – but this approach is suboptimal
- We should be doing it earlier and less frequently
o Absolute mortality reduction depends on follow-up – 8-10 years is not very meaningful
- EORTC update with longer follow-up: NNT drops from 48 (12-years follow-up) to 7 – which is in line with many other tests accepted for screening More recently, an update to the USPSTF recommendation based on the input of urologists. Still in draft form.
1) Men age 55-69: Grade C recommendation
- Shared decision making
2) Men age 70+: Grade D recommendation
More in line with other institutions’ guidelines. Still not enough emphasis on high-risk groups. Still massively overstate the harms.
Unfortunately, the NCCN is the only guideline that suggests baseline testing at younger age, which may be more appropriate, per Dr. Cooperberg. He cited the Malmo cohort study (Swedish study) regarding baseline testing at age 50.
Lastly, PSA should not be used in isolation. Various nomograms and even secondary testing may help risk stratify patients.
Presented by: Matthew Cooperberg
Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, Twitter: @tchandra_uromd at the 37th Congress of Société Internationale d’Urologie - October 19-22, 2017- Lisbon, Portugal