US officials publish new prostate cancer advice

An influential U.S. government health panel is dropping its opposition to routine prostate cancer screening.

In fact, in new draft guidelines the U.S. Preventive Services Task Force says they do not have any specific advice on the topic.

Instead, men should decide for themselves the best course of action after talking with their doctor.

The move echoes those of several leading medical groups, which are all warning they don’t have an answer.

But they don’t make the decision any easier for men: With their doctor’s help, they have to decide whether to take an imperfect PSA test that has a small chance of detecting a deadly cancer and a larger chance of triggering unneeded worry and treatment with serious side effects.

In new draft guidelines the U.S. Preventive Services Task Force says they do not have any specific advice on the topic. In 2012, the panel advised against ‘inaccurate’ PSA screenings

The panel’s chair Dr. Kirsten Bibbins-Domingo, a San Francisco internist who already follows the advice and discusses the potential pros and cons with her patients, insists the lack of advice is useful for men.

‘This isn’t a one-size-fits-all’ recommendation, she said. 

Men whose greatest concern is reducing their chances of dying from cancer are sometimes willing to face the consequences and choose testing. ‘Other men will realize the likely benefit is small and aren’t willing to risk the harms,’ she said.

PSA screening to detect the most common male cancer is among the most heated topics in men’s health. 

It involves a simple blood test for elevated levels of a protein that may signal cancer but also can be caused by less serious prostate problems. It can find cancer that frequently doesn’t need treatment because it’s too small and slow growing to become deadly. 

Doctors say there’s no good way to tell which early cancers might become lethal. The next step is often radiation or surgery to remove the prostate, which may result in impotence and incontinence.

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The U.S. Preventive Services Task Force says its latest recommendation is based on new evidence indicating that routine PSA blood tests can slightly reduce some men’s chances of dying from prostate cancer and that drastic treatment can be avoided with close monitoring when cancer is detected.

The shift shelves the panel’s 2012 guidance, which prompted criticism from some urologists – specialists who treat the disease – and angered some prostate cancer patients certain that PSA screening had saved their lives.

The new advice published Tuesday closely aligns the panel with medical groups that also support shared-decision-making. 

The biggest remaining difference is timing. The task force draft says screening conversations should begin at age 55. Other groups say start earlier, depending on family history of prostate cancer and other factors. It recommends against testing men aged 70 and older.

The panel leaves open how often men should be screened. It does not recommend earlier testing for blacks and those with a family history but says they should know their risks are higher.

Dr Eric Klein, chairman of the urology department at the Cleveland Clinic, told Daily Mail Online the new advice is a welcome evidence-based change, and one that is in his opinion long overdue.

‘Having worked in urology before PSA tests in the 1980s, I have personally seen the value, and I will always take the view that it does more good than harm,’ he said. 

‘When I became a urologist, the most common treatment we had – or rather, the only treatment – was removal of the testicles. 

‘Five years later, when we had PSA, the rate of men diagnosed with severe cancers went from 50 percent to 5 percent.

‘So it’s always been my belief, based on that experience, that it has value.

‘Of course, it is not necessary for all men. But to say it does not have value [as the US Preventive Services Task Force said in 2012] is incorrect, in my opinion.’

He added that he still takes issue with some elements in the new draft guidelines – he disagrees with the claim that men over 70 do not need to be screened at all, and he points out that they do not mention other, more effective tests than PSA, such as the blood-based OPCO4K, ISOPSA, and the Prostate Health Index.  

But in general, he joins the rest of the urology community celebrating the news. 

‘I welcome the change in recommendations and the emphasis on shared decision making – there is a lot of data in the primary care literature showing that men want to be informed about PSA and make a shared decision with those they trust,’ he said.

‘The newer recommendation should empower men to be proactive about learning about the benefits and risks of screening and not avoid asking about it because their personal physician is not a believer in screening and never even broaches the subject; men should ask for the facts and not be shy about asking to have a PSA ordered if they feel it’s in their interest to do so.’ 

Dr. Meir Stampfer, a Harvard University cancer expert, called the new advice ‘a more reasoned approach.’ He said PSA tests make sense if they do not lead to overly aggressive treatment. His research suggests that more than 1 in 5 men worldwide have undetected prostate cancer, including more than 40 million Americans, but that most will die of other causes.

The task force’s 2012 advice against screening said there was little evidence that PSA screening was reducing deaths. Since then, PSA screening rates have declined by as much as 10 percent, and now fewer than one-third of U.S. men get the tests. Fewer men are being diagnosed with early-stage disease, when it is more treatable, while more are being diagnosed with more aggressive harder-to-treat cancer.

The panel says its new advice stems from long-term research indicating that for every 1,000 men offered PSA screening, one to two will avoid death from prostate cancer and three will avoid prostate cancer spreading to other organs.

Newer research also has shown benefits from ‘active surveillance’ of men whose initial PSA tests and biopsies indicate slow-growing cancer that hasn’t spread, the panel said. This approach includes repeated PSA tests and close monitoring, which can delay or even avoid the need for treatment.

The task force’s recommendations influence U.S. government policy and are widely followed by primary care physicians. Medicare and many private insurers have continued to pay for the screening. The government-appointed volunteer panel reviews evidence and issues advice for a variety of screenings and treatments.

‘It sounds like cooler heads have prevailed,’ said Dr. Jim Hu, a urologist and prostate cancer specialist at New York-Presbyterian/Weill Cornell Medical Center who called the old advice ‘draconian’.

The prostate cancer recommendations, announced online in the Journal of the American Medical Association, are open for public comment on the task force websiteuntil May 8. Final guidance will come months later but the panel’s guidelines typically echo its draft advice.