The U.S. Preventive Services Task Force (USPSTF) revised its previous decision regarding prostate-specific antigen (PSA) testing in men aged 55 to 69 with no symptoms or history of prostate cancer.
The upgraded guidelines now state patients in this demographic should discuss the tests' potential benefits and side effects with their doctors and decide on their own accord whether to pursue this option or not.
The adjusted proposal — currently awaiting feedback from the public before it is finalized — changes the former D rating, which discouraged screening, into a C, leaving the choice up to personal "values and preferences."
However, the federal task force still advises against PSA testing in men older than 70. For this age group, the D rating is maintained because the potential benefits of routine screening continue to be outweighed by the side effects, shows the draft recommendation.
PSA Screening Pros And Cons
PSA screening is a commonly used blood test that measures the levels of a protein produced by the prostate gland. The problem is high levels of this protein may indicate in equal measure two conflicting outcomes: they can be construed as a sign of cancer but could also signal an infection or a benign enlargement of the prostate.
The biggest shortcoming of the PSA test is that, although it can detect small prostate tumors in their incipient, most treatable stage, the screening doesn't distinguish dangerous malignant cancers from the ones that have small chances of progressing over time and becoming a health threat.
The test, widely adopted for almost three decades, "misses as many prostate cancers as it finds", says Dr. Otis Brawley, chief medical officer of the American Cancer Society.
Consequently, it has been associated with a high percentage of false alarms, putting patients with benign tumors at risk for aggressive treatments. Even if the test detects an actual malignancy, many prostate cancers grow so slowly that they never become life-threatening.
In many situations, men faced with a positive result often undergo unnecessary biopsies or even radiation therapy and surgery for prostate removal, which can both cause urinary incontinence and long-term impotence.
This explains why, in 2012, the panel issued an official statement recommending against PSA testing for all patients, irrespective of their age.
What Happens After PSA Screening?
According to the National Cancer Institute, prostate cancer is one of the most common and deadly cancers among men. It is the second most widespread type of cancer in U.S. men, after skin cancer. Roughly 3 million American men are currently living with prostate cancer, with nearly 180,000 new cases were diagnosed in 2016.
Moreover, prostate cancer is the second leading cause of cancer-related fatalities in men. A minimum of 26,000 patients succumb to the disease every year.
But with no effective way to tell the dangerous prostate cancers from the harmless ones, most men undergo surgery or radiation after diagnosis. Another option of dealing with prostate cancer is active surveillance, which essentially means monitoring tumor growth rates to see whether they become alarming or not.
A study published last year concluded that all three cancer treatments are equally effective, revealing the survival rate for early stage prostate cancer is 99 percent after 10 years, regardless of whether the patient has opted for surgery, radiation, or active monitoring.
The only difference between the three alternatives resides in the quality of life outcomes — procedure, side effects, and how they impact the life of cancer survivors.
New Evidence Supports PSA Test's Benefits
The USPSTF is basing its turnabout decision on the results of several studies performed in the last five years, which corroborate the advantages of PSA screening.
One in particular — the European Randomized Study of Screening for Prostate Cancer (ERSPC) — discovered the test reduces the likelihood of developing advanced prostate cancer, as well as the risk of succumbing to the disease, by approximately 30 percent and 20 percent respectively.
"The new evidence allowed us to say that, on balance, we think now the benefits do outweigh the harms," says Dr. Kirsten Bibbins-Domingo, USPSTF chairwoman and a professor at the University of California.
In addition, the task force points out that the increasing prevalence of active surveillance minimizes the harms of screening. This is why the panel recommends that patients talk with their doctors and evaluate if PSA screening is the right choice for them.
"This is not a recommendation that says men should go get screened. This is a complex decision. Some men will want to avoid the chance of dying of prostate cancer no matter what, while others, given the side effects, will not think the benefits are worth it," explained Bibbins-Domingo.
Positive Reactions To The Guidelines Change
The revised draft recommendation was met with approval by urologists and U.S. cancer associations.
The American Cancer Society, for instance, also supports "shared decision-making" in which men and their doctors discuss the pros and cons. Dr. Brawley believes the new guidelines "would decrease confusion" about the screening procedure and what follows after a positive result.
"Some men who are very concerned about prostate cancer will elect to be screened, and others who are less concerned will elect not to be screened; either decision should be supported," he said.
The American Urological Association described the draft as "thoughtful and reasonable," mentioning its own guidelines are now in "direct alignment" with the USPSTF.
However, the association doesn't agree men 70 and older should be advised against PSA screening, suggesting these patients could benefit from the test.
At the same time, the Sidney Kimmel Comprehensive Cancer Center states the guideline shift reflects the increased use of active surveillance for low-risk prostate cancer.
"That's an antidote to overdiagnosis and overtreatment," said William Nelson, the center's director.
