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U.S. Preventive Services Task Force Revisits Prostate Cancer Screening

In a preliminary draft, the USPSTF recommends against prostate-specific antigen screening.

On October 11, 2011, the U.S. Preventive Services Task Force (USPSTF) posted a draft recommendation statement on screening for prostate cancer. In its 2008 guideline on this topic, the USPSTF concluded that evidence was insufficient to make a recommendation in men younger than 75, but it recommended against screening older men (age, 75). Now, 3 years later, the USPSTF recommends against prostate-specific antigen (PSA)-based screening for prostate cancer in all age groups.

The impetus for the USPSTF's revisiting of PSA screening is the recent publication of mortality results from two large randomized screening trials (JW Gen Med Mar 18 2009). A U.S. trial showed no benefit from screening but was tainted by substantial screening outside the trial in the control group. A European trial showed a small statistically significant reduction in prostate cancer mortality in screened men; however, substantial overtreatment occurred (i.e., a very small proportion of men who underwent surgery or radiation therapy ultimately benefited from these interventions), and critics have voiced concerns about certain methodologic issues in this trial, too. In reaching its decision, the USPSTF drew the following conclusions from its review of the evidence:

• The magnitude of harms from screening (e.g., falsely high PSA levels, psychological effects, unnecessary biopsies, overdiagnosis of indolent tumors) is "at least small."
• The magnitude of treatment-associated harms (i.e., adverse effects of surgery, radiation, and hormonal therapy) is "at least moderate" — particularly because of overtreatment among men with low-grade disease.
• The 10-year mortality benefit of PSA-based prostate cancer screening is "small to none."
• The overall balance of benefits and harms results in "moderate certainty that PSA-based screening . . . has no net benefit."

I agree with this draft statement, which is a pre-release review and not the final recommendation. Public comment is invited through November 8, 2011, after which a final statement will be published. Nevertheless, the expected firestorm has erupted already. Advocates of screening have criticized the USPSTF analysis, and the American Urological Association issued a press release stating that "the USPSTF — by disparaging the [PSA] test — is doing a great disservice to the men worldwide who may benefit from the PSA test." Journal Watch will cover the final recommendation when it is published.

— Allan S. Brett, MD

Published in Journal Watch General Medicine October 27, 2011

Reader Remarks:

Review and add to remarks on this article

• Prostate Cancer Screening not useful ??
  Jose GROS-AYMERICH, Asistencia Médica Valdebernardo. E-28032 Madrid, Spain, 28 Oct 2011 1:20 PM EST
  Specialty: Oncology
  How many men would like never having a test that reassures them ?. H Lilja et al, from NY, published... [more]
• Perfect Test for Prostate Cancer vs Nothing
  Hal Lederman, Jewish Guild for the Blind, 31 Oct 2011 7:33 AM EST
  Specialty: Unspecified
  So the PSA test is not perfect. By the way, what else is there?? Are men supposed to wait until... [more]
• PSA screeening
  William O. Ameen, MD, walk-in clinic, North Carolina, 31 Oct 2011 7:33 AM EST
  Specialty: Family Medicine
  Ask any of my patients, including an asymptomatic 37 yo and a 64 yo classmate of mine, among the several... [more]
• evidence based medicine
  matthew m. kreps, 2 Nov 2011 1:31 PM EST
  Specialty: Internal Medicine
  the proposal for PSA screening mentioned by Gros-Aymerich sounds somewhat promising. regardless, the comments made by Lederman and Ameen seem... [more]
• Psa Screening
  Neil K. Hall, 2 Nov 2011 1:31 PM EST
  Specialty: Geriatric Medicine
  It is amazing how many physicians can't or won't see the truth staring them in the face when in conflicts... [more]
• PSA TESTING
  JL Brown, 23 Jan 2012 6:44 AM EST
  Specialty: General Practice
  There is a significant industry built up around prostate screening. Apparently, few men are benefiting from the test. More importantly,... [more]

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