New Prostate Recommendations Draw Mixed Reviews
A recent draft recommendation statement announced by the U.S. Preventive Services Task Force (USPSTF) regarding the prostate cancer screening has many physicians at odds as to how to use the new guidelines within their own practices. Two specialists at The Nebraska Medical Center weigh in with their thoughts on the suggested guidelines.
U.S. Preventive Services Task Force Recommendation Draft Statement
According to the draft statement, the USPSTF recommends against prostate-specific antigen (PSA)-based screening for prostate cancer for all men in the U.S. population that do not have symptoms that are highly suspicious for prostate cancer, regardless of age, race or family history. The Task Force did not evaluate the use of the PSA test as part of a diagnostic strategy in men with symptoms that are highly suspicious for prostate cancer, nor did it consider the use of the PSA test for surveillance after diagnosis and/or treatment of prostate cancer.
Task Force Rationale
Prostate cancer is the most commonly diagnosed non-skin cancer in men in the United States, with a lifetime risk of diagnosis estimated at 15.9 percent. Most cases of prostate cancer have a good prognosis, but some are aggressive; the lifetime risk of dying from prostate cancer is 2.8 percent. Prostate cancer is rare before age 50 years and very few men die of prostate cancer before age 60 years. The majority of deaths due to prostate cancer occur after age 75 years. As a result, the Task Force feels that there is moderate or high certainty that the screening has no net benefit or that the harms outweigh the benefits.
Charles Enke, MD, radiation oncologist
“When I started practice in the late 1980s, there was an epidemic of prostate cancer diagnoses,” says Dr. Enke. “The introduction of the PSA prostate screening in 1986 coincides with a significant reduction in prostate cancer mortality over the last 20 years. The five-year survival for a person who is diagnosed with prostate cancer today is 99 percent. I’m concerned that these recommendations will reverse this trend and we’ll start seeing an increase in mortality again.”
Dr. Enke’s recommends the following screening guidelines:
- Discuss screening African-American males beginning at age 45. These men are at higher risk for prostate cancer; the cancer is generally more aggressive and results in a higher mortality.
- Discuss screening men with a first-degree relative who has been diagnosed with prostate cancer at age 65 or younger, beginning at age 45. Heredity accounts for 10 to 15 percent of all prostate cancers.
- Do not screen men 75 years and older or those men who have other serious health problems with life expectancy under 10 years.
Chad LaGrange, MD, urologist
“PSA screenings have allowed us to diagnose prostate cancer before it has spread. Once it becomes metastatic, it’s incurable. I believe the problem in the United States is not that we are over-screening, but that we are over-treating prostate cancer. Physicians need to use better judgment as to whom we treat based on their risk factors, test results, life expectancy and a frank discussion with the patient.”
Dr. LaGrange recommends the following guidelines in determining who to treat: Review the Gleason score for the biopsy to determine the aggressiveness level of the tumor. Also use the PSA as a marker for tracking the growth of the tumor. Factors to consider when considering treatment include: PSA values according to age, health condition, tumor size, prostate size and rate of rise of PSA. Based on these factors, you can determine whether the tumor is likely to be aggressive or not. If it is determined that treatment is not supported, follow the tumor every six months to a year for the patient’s remaining lifetime.