Anti-PCa screening message unlikely to make waves

Despite another anti-prostate cancer screening message (this one from north of the border), many U.S. urologists have already taken a more individualized approach to screening and will likely continue to do so.

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That’s the message of a leading U.S. prostate cancer expert and Urology Times editorial consultant.

Late last month, the Canadian Task Force on Preventive Health Care (CTFPHC) released an updated guideline on screening for prostate cancer that recommended against screening with the PSA test in men of all ages. Similar to the May 2012 recommendation of the U.S. Preventive Services Task Force (USPSTF), the Canadian task force said its updated guideline is based on the balance between the possible benefits and potential harms of early diagnosis and treatment of prostate cancer.

The new guideline is published online in the Canadian Medical Association Journal (Oct. 27, 2014).

“Unfortunately the PSA test is simply not an effective screening tool,” said Neil Bell, MD, a task force member and chair of the guideline working group. “Almost 20% of men aged 55 to 69 have at least one false-positive, approximately 17% of them will have unnecessary biopsies, and over half of the detected cancers are overdiagnosed, which is the detection of cancers that would not have caused symptoms or death during the lifetime of the patient.

“False positives and overdiagnosis often lead to unnecessary treatments, which can lead to impotence, incontinence, infections, and other harms. Considering PSA screening results in only a 0.1% reduction in death from prostate cancer, the harms associated with screening outweigh the benefits for most people,” Dr. Bell said in a CTFPHC press release.

Next: "I don't think it will affect what urologists in the U.S. are already doing."

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J. Brantley Thrasher, MD, of the University of Kansas in Kansas City, said the recommendation was not surprising, and despite it coming from neighboring Canada, will probably have little impact on screening practices here.

“I’m not surprised, given the sentiment from their health care system,” said Dr. Thrasher, a Urology Times editorial consultant. “They’re the number one enroller of patients in active surveillance. I don’t think it will affect what urologists in the U.S. are already doing.”

“I think urologists in the U.S. have heard the call [about over-diagnosis and overtreatment] and are doing more individualized screening.”

Recommendations of the Canadian guideline include:

• For men younger than 55 years of age and 70 years of age and older, CTFPHC strongly recommends against screening for prostate cancer with the PSA test. There is no evidence that screening with PSA tests reduces mortality, whereas there is evidence of harms.

• For men aged 55–69 years of age, the CTFPHC does not recommend screening for prostate cancer with the PSA test. There is inconsistent evidence of small potential benefit of screening, and evidence of harms. This recommendation places a relatively low value on a small potential absolute decrease in prostate cancer mortality, and reflects concerns with false-positive results, unnecessary biopsies, overdiagnosis of prostate cancer, and the harms associated with unnecessary treatments.

“We recognize that some men 55–69 may place a higher value on the small potential in reduction of death than on the higher risk of the undesirable consequences that come with PSA testing,” said James A. Dickinson, MB BS member of the task force and guideline working group. “Doctors should be prepared to candidly discuss all of the risks in comparison to the benefits, so that these patients can make informed decisions. We’ve developed patient education tools to help with this process.”

The Canadian Urological Association (CUA) issued a statement in which it outlined a number of concerns about the CTFPHC recommendation.

“The recommendation advises strongly against PSA testing in men under age 55, acknowledging that this is based on poor quality evidence. This recommendation does not incorporate the compelling population-based data from Sweden [Cancer 2010; 117:1210-9] demonstrating that baseline PSA is strongly predictive of the future risk of aggressive prostate cancer 20 to 30 years later, thus warranting less frequent screening in men with a low PSA,” the CUA wrote.

“The best trials available to date, which are still in progress, have demonstrated that screening reduces prostate cancer death by 21% to 44%,” the CUA added. “To recommend against screening because ‘Available evidence does not conclusively demonstrate that screening with the PSA test will reduce mortality from prostate cancer’ is misleading and reflects errors of fact, omission, interpretation, and statistics.”

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