The United States Preventive Services Task Force (USPSTF) recently completed a systematic review of the benefits and harms associated with screening for prostate cancer. In an update of their 2002 guidelines related to prostate cancer screening, the USPSTF now recommends against screening for prostate cancer in men aged 75 years or older.
The report also concludes, as it has previously, that the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75. While the USPSTF found convincing evidence that testing for early prostate cancer with prostate-specific antigen can detect some cases of prostate cancer, it also found there is not adequate evidence in men under age 75 years to determine whether treatment for prostate cancer detected by screening improves health outcomes compared with treatment initiated for symptomatic disease. In men aged 75 years or older, the USPSTF concluded that the incremental benefits of treatment for prostate cancer detected by screening are small to none. These updated guidelines were published in the Annals of Internal Medicine (149;3:185–188).
“Testing for early prostate cancer detection is a major decision facing average-risk men aged 50 and older, as well as younger men at higher risk,” said Robert Smith, PhD, Director of Cancer Screening for the ACS.
In recent years, prostate-specific antigen testing has become very common. In 2007, approximately 218,890 men received a prostate cancer diagnosis, according to USPSTF.
“At the center of the uncertainty about the balance of benefits and harms related to testing for early prostate cancer detection,” says Smith, “is the fact that treatment for prostate cancer can cause moderate-to-substantial harms, such as erectile dysfunction, urinary incontinence, bowel dysfunction, and death. While some prostate cancers are aggressive and life-threatening, others grow so slowly that they may never have produced symptoms or may not have progressed to a point where they are life-threatening before a man dies from other causes. Since aggressive therapy for disease that is presumed to be life-threatening, but in fact is indolent or very slow growing, can measurably reduce quality of life, there are serious and yet unanswered questions about the balance of benefits to harm related to treatment of disease detected by screening that may never have produced symptoms or have become life-threatening.”
ACS Chief Medical Officer, Otis Webb Brawley, MD, explains that the ACS does not have a blanket recommendation for prostate cancer screening for men over the age of 50.
“The ACS recommendation recognizes the limits of the science and suggests that men be involved in the decision to be screened or not be screened. We do not put an upper age limit on who should be given the option of screening but suggest that men with less than a 10-year life expectancy not be screened. The average 75-year-old American male has a life expectancy of about 10 years. The ACS recommendation recognizes that there are some 75- and 80-year olds in better-than-average health with more than a 10-year life expectancy, and we recommend they be given the option of screening.”
“The ACS also recommends that men at high risk for prostate cancer be given the option of screening beginning at age 45. Men at high risk include men with a family history, meaning a brother, father, grandfather, or uncle with a diagnosis of prostate cancer. Men of African heritage are also considered at high risk,” said Brawley.
The USPSTF panel says results of good-quality randomized, controlled trials are needed to determine whether prostate cancer screening actually has an effect on prostate cancer deaths, and ACS's Smith agrees. “The ACS annually reviews the scientific literature on cancer screening to determine when a formal update should be undertaken. ACS guidelines for testing for early prostate cancer detection were last updated in 2002. At this time, there are two large, prospective clinical trials underway to evaluate the efficacy of prostate cancer screening: the U.S. Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial and the European Study of Screening for Prostate Cancer. While the final results of these trials are anticipated in the near future, it is not known precisely when in the next few years or longer final results will be published. Until those studies are completed, a major revision or change in the current ACS recommendations, or any other organization's guidelines, is unlikely.”