Dear USPSTF: Don’t discount value of PSA in men 70+

Editor’s note: The following letter was sent to the U.S. Preventive Services Task Force (USPSTF) in April 2017 after the USPSTF’s release of an updated draft recommendation on prostate cancer screening. The letter was subsequently sent to Urology Times following publication of an article discussing urologists’ reaction to the recommendation.

Dear USPSTF,

According to the draft USPSTF statement regarding prostate cancer screening:

“For men 70 years and older, the draft recommends against PSA-based screening for prostate cancer (D recommendation). The evidence shows that prostate cancer is slow growing, and the 10-year survival rate is quite high. Rates of overdiagnosis are higher in older men, raising the concern that screening may result in more harm than benefit in this age group.”

We have published three papers in peer-reviewed urology journals focusing on patients 70 years and older. These publications show that men 70 years and older have much higher rates of high-grade (Gleason score 7-10) prostate cancer, higher stages of prostate cancer, and higher prostate cancer-specific morbidity and mortality compared with patients 55-69 years old.

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In 2013, we published, “A comparative analysis of prostate cancer pre-treatment characteristics stratified by age” (Can. J. Urol 2014; 21:7213–6). In our 402 U.S. patients, we found that, compared with patients <70 years old, in patients ≥70 years old:

• 60.7% had high Gleason score (7-10) (p=.0234)

• 39.3% had low Gleason score (6) (p=.0234)

• 1% had PSA level ≥10 ng/ml (p=.0010)

• 69.1% had high Gleason score (7-10) in the presence of a positive DRE (p=.0278).

In 2016, we published the largest review ever of 5,100 U.S. prostate cancer patients age 70 and older, “Frequency of Gleason score 7 to 10 in 5,100 elderly prostate cancer patients” (Rev Urol 2016; 18:181-7) and found that:

Based on analysis of 5,100 prostate cancer patients in our practice, we determined that 61% of prostate cancer patients age 70-80, 59% of those age 70-75 years, and 66% of those age 76-80 years have a high-grade prostate cancer. Since biopsy underestimates the grade in Gleason score 6 patients by about 50%, the actual frequency is approximately 80%. In patients with prostate cancer who had an abnormal DRE, 74% had a Gleason score 7-10, approximately 85% when accounting for biopsy undergrading.

In 2017, we published a review of our patients titled, “Prostate biopsy characteristics: A comparison between pre- and post-USPSTF Prostate Cancer Screening Guidelines of 2012” (Rev Urol 2017; 19:25–31). In this study of 671 U.S. prostate cancer patients, we found that the prostate biopsy rate decreased by 30% post-USPSTF guidelines but the prostate cancer detection rate increased by 33.5%. High-grade Gleason score 7-10 prostate cancer increased by 5.4% post-USPSTF guidelines.

Next: "Since the USPSTF recommendations of 2012, more advanced prostate cancer, metastatic prostate cancer, and prostate cancer-specific deaths have been documented."

Since the USPSTF recommendations of 2012, more advanced prostate cancer, metastatic prostate cancer, and prostate cancer-specific deaths have been documented. A recent study showed that the incidence of metastatic prostate cancer increased by 72% from 2004 to 2013 (Prostate Cancer Prostatic Dis 2016; 19:395-7). The 5-year survival rate in metastatic prostate cancer is 28% (American Cancer Society, 2017), and the cost of treating metastatic prostate cancer is extremely high. More importantly, patients with metastatic prostate cancer have more pain and a much lower quality of life with certain death. The annual cost of the screening PSA test for prostate cancer is $28.

In the last 20 years, due to prostate cancer screening, the prostate cancer mortality has been reduced by 50% (JAMA Oncol 2016; 2:955-6). Additionally, African-Americans have twice the prevalence and twice the death rate due to prostate cancer compared to Caucasians.

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Diagnosis is necessary for proper medical care. All patients with prostate cancer do not undergo surgical or radiation therapy, as some patients are actively observed. In addition, newer technologies like parametric MRI of the prostate gland helps to differentiate slow-growing from aggressive prostate cancer. Thus, medical research improvements will help us in future investigations and treatment of prostate cancer, especially of aggressive tumors.

We strongly believe that PSA-based prostate cancer screening should be made available, especially to men 70 years and older to decrease the morbidity and mortality of prostate cancer.

Sincerely,

Navin Shah, MD, and Vladimir Ioffe, MD, Greenbelt, MD

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