An influential federal task force has dropped its controversial opposition to routine screening for prostate cancer and now says that men between the ages of 55 and 69 should discuss the test’s potential benefits and harms with their doctors and make decisions based on their own “values and preferences.”
“The decision about whether to be screened for prostate cancer should be an individual one,” the U.S. Preventive Services Task Force said in a draft recommendation issued Tuesday.
The statement marks a turnaround from the panel’s 2012 stance, which concluded that any potential benefit from the PSA test — for prostate-specific antigen — was outweighed by possible harms. Those include a high percentage of false positives as well as potentially devastating side effects from the aggressive treatment of slow-growing malignancies that might never pose a health threat. Surgery and radiation can cause urinary incontinence and sexual impotence.
The draft recommendation says that, on balance, screening provides a small benefit for men ages 55 to 69. New evidence “increases confidence” that the PSA test reduces the risk of dying of prostate cancer or developing advanced cancer that spreads beyond the prostate.
In addition, the task force noted, an increasing number of men with low-risk cancer are opting for “active surveillance,” which involves regular PSA testing, repeated rectal examinations and biopsies rather than aggressive treatment. That approach reduces the risks of injury from overtreatment, it said.
Yet “the balance of benefits and harms is still close,” said Kirsten Bibbins-Domingo, an internist at the University of California at San Francisco and task-force chair. “This is not a recommendation that says men should go get screened. This is a complex decision. Some men will want to avoid the chance of dying of prostate cancer no matter what, while others, given the side effects, will not think the benefits are worth it.”
The panel’s shift is the latest chapter in a long saga over prostate-cancer screening. Its 2012 recommendation brought a torrent of criticism from some urologists, who warned that it would lead to decreased screening and increased deaths. The American Urological Association denounced the decision as a “disservice” to men.
But while some groups still recommend regular PSA tests, many have tempered their views. The American Cancer Society, for example, endorses “shared decision-making” in which men and their doctors discuss the pros and cons. Otis Brawley, chief medical officer of the cancer society, said the new task-force recommendation was an important step and “would decrease confusion.”
And the urological association called the draft recommendation “thoughtful and reasonable,” saying it was now in “direct alignment” with its own guidelines. At the same time, the specialty group took issue with the panel’s decision to maintain its recommendation against screening for men 70 and older, saying that healthier older men might benefit from the test.
William Nelson, director of the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University, said the guideline shift reflects the increased use of active surveillance for low-risk prostate cancer. “That’s an antidote to overdiagnosis and overtreatment,” he said.
Some primary-care physicians are unhappy about the task force’s change, however.
“I think they punted,” said Daniel Merenstein, a family-medicine physician at the Georgetown University School of Medicine. He worries patients and doctors will think the panel concluded that it had made a mistake “and that it’s all right to go back to a lot more screening and aggressive treatment.” He said he also doubts harried primary-care doctors will have time to guide patients through complicated discussions on PSA testing, given the importance of talking about other issues like diet, exercise and colonoscopies.
More than 161,000 men in the United States will be diagnosed with prostate cancer in 2017, according to the cancer society, and almost 27,000 men will die of the disease. The task force says the median age of death is 80.
Almost 3 million American men are currently living with prostate cancer. But with no effective way to tell the dangerous prostate cancers from the harmless ones, most men undergo surgery or radiation after diagnosis. Studies published last fall concluded that the survival rate for early-stage prostate cancer is 99 percent after 10 years, regardless of whether a man opted for surgery, radiation or active monitoring.
The PSA test, adopted widely beginning in the 1990s, detects the level of a protein, produced by the prostate gland, in a man’s blood. An elevated level can be due to cancer but also can reflect a benign condition such as an enlarged prostate. In recent years, concerns grew over the side effects of treatment. The task force said that about 1 in 5 men who have their prostates removed suffer long-term problems with urinary incontinence that require pads. Two-thirds have long-term impotence.
But in the wake of the panel’s 2012 recommendation, screening dropped significantly. That prompted some urologists to warn that the number of men diagnosed at a late stage would inevitably rise, resulting in more deaths. Some physicians say such a trend has already begun, but others disagree. Bibbins-Domingo said she thinks “it’s highly unlikely that a reduction in screening led to a rise in metastatic disease,” primarily because of the timing. It can take several years for screening changes to affect cancer rates.
New York real estate executive Stephen Fredericks, 63, is a proponent of PSA testing. A decade ago, his PSA levels gradually began climbing even though several biopsies were negative for cancer. Eventually, as the test continued to show an increase, his doctor ordered an MRI, discovered a mass and did surgery. “When all the biopsies failed,” he said, “the only thing that kept my attention focused on this was the PSA numbers.”
The task force’s initial recommendation generated political heat, and in 2015 Reps. Marsha Blackburn (R-Tenn.) and Bobby L. Rush (D-Ill.) introduced legislation to “reform” the independent panel and add specialists to the prevention experts appointed by a federal health agency. Their effort followed years of criticism from lawmakers and advocacy groups over the panel’s recommendation on mammography — that regular screening shouldn’t start until age 50.
Bibbins-Domingo said the revised position on prostate-cancer screening wasn’t due to political pressure but reflects the updated evidence on the balance of benefits versus harms. The task force said new data show that PSA screening in the younger group prevents 1 to 2 deaths from prostate cancer over 13 years per 1,000 men screened.
The 2012 recommendation gave universal screening a D grade, meaning the potential benefits did not outweigh the harms. The new draft guideline leaves that in place for men 70 and older but gives a C grade to screening for men ages 55 to 69, signaling that the decision should be an individual one after consultation with a physician.
Jim Hu, a urologic oncologist at Weill Cornell Medicine and New York-Presbyterian, praised the recommendation reversal. “They are opening it up to say, ‘Have a talk with your doctor, and hey, this is an individual decision.’”
Most prostate cancers “are snails or slugs or tortoises,” Hu said. “Once you find it, it tends to grow slowly.”
Because of a lack of evidence, the task force said that it wasn’t able to make specific recommendations for African American men, who are at higher risk of the disease. It called for more research for this group.
The draft recommendation will be open for public comments until May 8.