USPSTF Re-evaluates PSA Testing; Here's Their Plan

Nick Mulcahy

May 04, 2016

The US Preventive Services Task Force (USPSTF) is updating its controversial guidance about prostate cancer screening, and a final research plan was published online last week.

The plan will guide a systematic review of the available evidence on prostate cancer screening.

In turn, the systematic review "will form the basis of the Task Force's updated recommendation statement on this topic," according to the USPSTF website.

In 2012, the organization formally recommended against routine prostate-specific antigen (PSA)-based prostate cancer screening for healthy men, regardless of age.

However, the document left room for use of the test in the clinic. "Clinicians should understand the evidence but individualize decision-making to the specific patient or situation," read the final document, which was published in Annals of Internal Medicine (2012;157:120-134).

Nonetheless, use of the PSA test has since dropped, especially among primary care providers, as reported by Medscape Medical News.

In their research plan, the USPSTF will be looking at multiple "key questions."

The very first question addresses higher-risk men: "Does the effectiveness of PSA-based screening vary by subpopulation/risk factor (e.g., age, race/ethnicity, family history, and clinical risk assessment)?"

But the question might not be fully answerable, said Richard Hoffman, MD, MPH, an internist at the University of Iowa in Iowa City, and an expert in shared decision-making about prostate cancer screening.

Finding high-quality data to answer this will be challenging.

"Finding high-quality data to answer this will be challenging," Dr Hoffman told Medscape Medical News. None of the major screening trials enrolled men younger than 50 years, most subjects were white, and investigators did not routinely assess clinical risk.

"While some studies are now recruiting patients to address screening in higher-risk populations, it will likely take at least a decade to determine the effects of screening on morbidity and mortality," he summarized.

In the meantime, Dr Hoffman is concerned that "abandoning PSA screening" is proving harmful.

The rate of distant-stage prostate cancers in the United States is increasing, according to a population-based study for which he was lead author (Cancer Epidemiol Biomarkers Prev. 2016;25:259-263). However, "it's too early to tell whether this will lead to an increase in prostate cancer mortality," he said.

The USPSTF research plan separates the review of evidence about the potential harms of PSA testing, biopsy, and treatment.

This separation is a good idea, said Dr Hoffman.

"While the literature on biopsy harms is pretty comprehensive, we still need to better understand the implications of overdiagnosis and overtreatment," he pointed out.

Emerging evidence on the benefits and harms of active surveillance is an especially important area of research.

"Many experts believe that the harms of screening can be mitigated by withholding active treatment for men whose cancers appear unlikely to ever cause clinical problems," Dr Hoffman explained.

It is incumbent on us to come up with smarter screening strategies.

No matter what the USPSTF recommends, urologists must lead the way with their own PSA testing guidance, said Jesse D. Sammon, DO, a urologist from Brigham and Women's Hospital in Boston. "It is incumbent on us to come up with smarter screening strategies."

Dr Sammon believes that current recommendations from the American Cancer Society and the American Urological Association have evolved intelligently.

Both organizations now recommend joint decision-making about PSA testing with men 55 to 69 years of age. "The great survival benefit [of the testing] is in this age group," he told Medscape Medical News.

Therefore, the mortality benefit justifies consideration of the test, in spite of the known risks, Dr Sammon argued.

Dr Hoffman is a consultant to the Informed Medical Decision Foundation in Boston. Dr Sammon has disclosed no relevant financial relationships.

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