Prostate Cancer Diagnoses Drop After USPSTF 'Don’t Screen'

Roxanne Nelson, RN, BSN

September 22, 2015

Prostate cancer diagnoses decreased by 28% in the first year following the US Preventive Services Task Force (USPSTF) recommendation against regular prostate specific antigen (PSA) screening, according to a new analysis published online September 22 in the Journal of Urology.

Diagnoses of low-, intermediate-, and high-risk prostate cancers declined significantly during that period, although new diagnoses of nonlocalized disease did not change.

It is not surprising that new diagnoses of nonlocalized disease have remained the same, explained lead author Daniel A. Barocas, MD, MPH, of the Department of Urologic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee. "Our data go to 2012, so it's really only a year since the guideline was issued," he said. "I would have not expected to see a change at this point in time."

In October 2011, the USPSTF recommended against routine screening for prostate cancer using the PSA test, which has caused considerable controversy among professional organizations, patient advocacy groups, and physicians. Prior to this, the USPSTF had already recommended against routine PSA screening in men older than 75 years, but the new guidelines extended it to all men. PSA testing was given a "D" rating, which means "there is moderate or high certainty that the service has no benefit or that the harms outweigh the benefits."

Some of the effects of this guideline may be beneficial in terms of reducing harms related to overdiagnosis and overtreatment, Dr Barocas told Medscape Medical News. "But not only are we missing low-risk diagnoses, we are also missing diagnoses of intermediate- and high-risk disease. A delay in the diagnosis for those patients could lead to worse outcomes."

Previous research has suggested that higher-risk disease could be on the increase because of the decline in screening. One study found that the rate of higher-risk prostate cancer rose slightly but significantly in the United States during 2011 and 2012. The 3% increase in each of those 2 years coincides with the changes that were made in USPSTF prostate cancer guidelines in 2009 and 2011.

Without screening, many of these cancers will not be detected until they are advanced, Dr Barocas continued. "Patients are generally not symptomatic until the disease is more advanced and may be difficult to treat."

But even 1 year after the recommendations, he noted that they were already seeing reductions in the diagnosis of intermediate- and low-risk disease. "We saw an almost 30% reduction in the diagnosis of intermediate prostate cancer," he said. "A decline of that magnitude is huge. This shows that we are missing important opportunities to treat these men with curative therapies."

As time goes on, the full impact of the guidelines will become more apparent. "In a year or two, we will have a better idea of the impact that they are having, especially in men with high-risk disease," Dr Barocas said.

Diagnoses Drop Within 1 Year

Using data from the National Cancer Database, the authors sought to determine whether the number of incident cases of prostate cancer per month has substantially changed since the advent of the guideline. They assessed the trend of new prostate cancer cases that were diagnosed each month before and after the draft guideline.

The bulk of new cases were diagnosed in men between the ages of 60 and 69 years (43.7%), and the majority were white (80%).

There was a small predominance of intermediate-risk disease in localized cases as compared with low- and high-risk disease (32.2% vs 25.4% vs 27.0%); 5.4% of patience had nonlocalized disease at diagnosis.

Prior to the introduction of the guideline, the number of monthly diagnoses of prostate cancer ranged from 9442 to 12,021, and diagnoses were increasing by approximately 45 cases per month (0.4%).

In October 2011, however, there was a significant and immediate reduction in estimated diagnoses of incident disease of -1373 cases, along with a significant change in trend in the periods before and after the guidelines were issued. This represented a relative decrease of 164 cases per month, corresponding to a change of -12.2% (P < .01) in incidence in the month that immediately followed the publication of the guidelines. After that, there was an ongoing rate of decrease of -1.8% per month (P < .01).

A year after its release, the number of new diagnoses had declined by 27.9% as compared with the projected trend from the period before the guideline was issued.

When looking at the different subgroups, diagnoses declined in all risk categories. The initial decrease in monthly diagnoses was -16.9% for low-risk, -12.9% for intermediate-risk, -10.1% for high-risk, and -2.7% for nonlocalized disease. The corresponding monthly changes thereafter were -2.7%, -1.9%, -1.4% and -0.1%, respectively (P-interaction < .01).

"This study clearly shows how important it is to utilize PSA for appropriately managing various stages of prostate cancer, including initial diagnosis, and to avoid overutilization," commented Khurshid Guru, MD, associate Professor of oncology in the Department of Urology at Roswell Park Cancer Institute, Buffalo, New York, who was approached by Medscape Medical News for an independent comment.

Dr Barocas and his colleagues agree. They call for more research that focuses on screening paradigms that will minimize harms but at the same time maximize the potential benefits of screening and take into account individual patient risk factors and preference.

Dr Barocas has a financial interest and/or other relationship with Astellas, MDxHealth, Janssen, and Tolmar. Coauthor Sam S. Chang, MD, has a financial interest and/or other relationship with Bayer, Astellas, Janssen, and Tolmar.

J Urol. Published online September 22, 2015. Abstract

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