Federal panel changes its mind on prostate cancer screening
"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 negatives 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.
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