Task force changes opinion on prostate cancer screening

Men’s doctors say that updated recommendations in favor of prostate cancer screening from a national panel of medical experts now fall in line with advice and practice already in place. In a reversal of its 2012 opinion, the U.S. Preventive Services Task Force reported Tuesday it now supports screening for men ages 55 to 69, after patients discuss the decision with their doctors.

The task force years ago said the benefits of screening didn’t outweigh the harms enough to recommend screening. In Tuesday’s Journal of the American Medical Association, a review of evidence showed screening was more successful in reducing the risk of dying of prostate cancer and the risk of the cancer spreading.

Screening is not recommended for men 70 years old and up if they have no symptoms, because it can take at least 15 years after earlystage cancer is detected before it becomes life-threatening.

Ralph Miller, director of the Allegheny Health Network Prostate Center, said the screening for prostate-specific antigen, or PSA, has been available for more than 25 years, and the task force advice now puts it back in the mainstream of medical practice. A half-dozen other medical associations, including the American Cancer Society and the American Urological Association, advise

that the decision for testing should be made on an individual basis.

“Most men should at least have the conversation with their doctor,” said Florida oncologist Daniel Landau of the Orlando Health UF Health Cancer Center, whose practice is 60 percent prostate cancer patients.

The task force’s earlier advice against PSA screening caused controversy, Dr. Landau said.

“Urologists didn’t agree; many patients didn’t agree. After that, the use of the PSA test dropped a lot, more men were developing metastatic prostate cancer.”

Dr. Miller said men interested in their health now talk to their doctors regularly about the pros and cons of screening.

“Shared decision making is a trend in medicine; it’s the current state-of-the-art best practice,” Dr. Miller said. “A large part have been screened for a while. Now you’re not starting from ground zero. They have a fair amount of sophistication.”

Over the past decade many men have had the screening, tested positive and instead of surgery right away have opted for active surveillance, or “watchful waiting.” The practice of watching low-risk cancers may be reducing the risk of harms from screening, the task force said.

The report in JAMA said that studies still show that screening poses harms to patients, such as false positive results, complications, overdiagnosis, psychological harms, and harms of treatment including urinary incontinence and erectile dysfunction.

Because African-American men and men with a family history of certain cancers have a higher risk for prostate cancer, the task force said it needs information and support to make informed decisions about screening.

More prostate cancers are being picked up early through the rise in screenings, according to David Friedland, oncologist at UPMC Hillman Cancer Center.

He said one of the larger studies cited in the task force report, however, had questionable results: Although it compared results of prostate screening in one group with results in a control group that had no PSA screening, the fact is that one-third of men in both groups had already had PSA tests.

“It’s not a pure experiment at all,” Dr. Friedland said, adding that the effects of screening might look even more positive if it was a true randomized trial, with both treatment and no-treatment groups.

However, he said, “It’s hard to do these kinds of studies. If you could be pure, I think it would come out in favor of screening. Now it’s confusing.”

Since screening has been on the rise again, he said, “We’ve seen mortality drop dramatically. Why else is this happening if not because of screening and aggressive treatment?” At the same time, he added, the PSA test isn’t perfect, and better techniques are needed for early detection.

He said good news in the field includes better hormone-based treatment and chemotherapy. And, he said, over his past 25 years as a cancer specialist, he has found men in the 55-69 age group are more informed and involved in their care.