Letter: USPSTF recommendation a disservice to high-risk men

July 9, 2018

"Although we commend the USPSTF for upgrading the recommendation for PSA- and digital rectal exam-based prostate cancer screening from a “D” to a “C” grade (JAMA 2018; 319:1901–13), we believe that not enough emphasis is placed on screening high-risk groups for prostate cancer," write Navin Shah, MD, and Vladimir Ioffe, MD.

To the editor:

Although we commend the USPSTF for upgrading the recommendation for PSA- and digital rectal exam-based prostate cancer screening from a “D” to a “C” grade (JAMA 2018; 319:1901–13), we believe that not enough emphasis is placed on screening high-risk groups for prostate cancer.

Our group of 12 board-certified urologists practicing in the Washington, DC metro region sees a high-risk patient population consisting of 60% African-Americans and 22% men over age 70. We reviewed our patient biopsy data before and after the 2012 USPSTF recommendation against PSA screening. We found that, of 1,194 prostate biopsies, 552 were positive (46%) and 60% were high grade (Gleason score 7-10), even though compared to pre-2012 the prostate biopsies decreased by 30% (Rev Urol 2017; 19:25–31). Our data indicate that the high-risk group consists of African-American men, men with a family history of prostate cancer, and healthy men age 70-80 years old and hence requires prostate cancer screening.

We disagree with the USPSTF regarding the basic statistic on which the recommendations are based. According to the USPSTF statement, 100 men need to be diagnosed with prostate cancer in order to avoid one death from prostate cancer. This statistic is derived from clinical trial data and is not consistent with the actual U.S. cancer statistics provided by the American Cancer Society (ACS). According to the ACS, in 2017 there were 161,360 new cases of prostate cancer and 26,730 deaths due to prostate cancer (CA Cancer J Clin 2017; 67:7–30). This means that for 100 men diagnosed with prostate cancer, 16 will die due to prostate cancer. We believe this discrepancy is due to the under-representation of high-risk groups in the clinical trial data upon which the recommendations were based.

Next:"We don’t want to return to the pre-PSA era in which 30% of newly diagnosed prostate cancer cases were metastatic."A recent analysis of PubMed showed 53 articles that reviewed the clinical value of PSA-based prostate cancer screening found that 75% were in favor of screening (Urology 2017; 104:122-30). Data since the original recommendation against screening in 2012 show increased rates of metastatic disease (Prostate Cancer Prostatic Dis 2016; 19:395-7). We don’t want to return to the pre-PSA era in which 30% of newly diagnosed prostate cancer cases were metastatic.

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 and genetic testing help to differentiate slow-growing from aggressive prostate cancer. Thus, new clinical tools will guide us in the future treatment of prostate cancer, especially of aggressive tumors.

We strongly believe, as stated in our prior letter published in Urology Times (July 2017, page 39), that PSA-based prostate cancer screening should be made available, especially to African-American men, men with a family history of prostate cancer, and healthy men age 70–80 years old to decrease the morbidity and mortality of prostate cancer. 

 

Navin Shah, MD, and Vladimir Ioffe, MD

 

Greenbelt, MD