Shared Decision Making Emphasized for Prostate Screening

New prostate cancer screening guidelines published by the U.S. Preventive Services Task Force (USPSTF) conclude that for men ages 55 to 69, opting to have PSA screening is an individual decision that should include a discussion with a physician about the benefits and potential harms. That marks a significant shift for the agency, which published guidelines in 2012 that recommended against screening for all men. The new guidelines still recommend against screening men age 70 and older.

Alex Krist, MD, MPH, the USPSTF vice chair, says the benefit of screening is a small increase in prostate cancer survival: After 13 years of follow-up in the ongoing European Randomized Study of Screening for Prostate Cancer (ERSPC), screening saved 1.27 lives per 1,000 men screened, up from 1.07 lives after 10 years, and prevented three men from developing metastatic disease.

Screening does come with potential harms, such as false positives, which can lead to unnecessary biopsies, and diagnosis of nonaggressive prostate cancer that may never become symptomatic, which can lead to unnecessary treatment.

Krist points out, however, that some of these harms have been reduced: More men with low-grade cancers are choosing active surveillance to monitor their disease instead of undergoing surgery or radiation. In fact, a recent study of more than 125,000 U.S. veterans with nonaggressive disease found 4% of those under 65 opted for active surveillance in 2005, compared with 39% in 2015.

Krist thinks that the new guidelines, which more closely align with those of the American Urological Association and the American College of Physicians, won't necessarily translate into more screening.

“This is a complex decision,” Krist says. “What I would like to see is that for the men who get screened and the men who don't get screened, it happens because it's lined up with their health needs, and their values, and their preferences.”

Krist adds that more research is needed on the value of screening men at high risk, including those with a family history and those of African American descent, who infrequently enroll in screening studies; on the differences between high- and low-risk prostate cancers; on how to minimize the harms of biopsies and treatment; and on the development of a better screening test.

Anthony D'Amico, MD, PhD, of Dana-Farber/Harvard Cancer Center in Boston, MA, thinks the new USPSTF guidelines are appropriate, based on the available evidence. However, he points out that there was only a 49% difference in screening between the screening and control arms in the ERSPC due to some screening in the control arm, and some nonattendance in the screening arm.

“The data that's available underestimates the true impact of PSA screening on cancer-specific mortality,” he says. With the new guidelines in place, “it's likely that PSA screening will go up a bit, but in my opinion, not as much as it should.”

Marc Garnick, MD, of Beth Israel Deaconess Medical Center in Boston, thinks the USPSTF made the right recommendation in 2012, and has “gotten it right again” in 2018.

“I think it's back to the future,” he says, referencing a return to more widespread screening. “The new guidelines emphasize a shared decision, which is going to result in more testing than not—it's going to increase the number of PSA tests, it's going to increase the number of biopsies, it's going to increase the number of diagnoses.”

He adds that since 2012 active surveillance has become more common, in part because improved genomic testing allows clinicians to better predict the disease's course.

“What we now have that we didn't have [before] is the ability for that patient to not go down that slippery slope of always getting treated,” he says. “Now you can diagnose and selectively treat, so the screening that in the past has invariably led to treatment does not equal harm.” –Catherine Caruso