Task force recommends against PSA screening in men over 75 years old

The U.S. Preventive Services Task Force has updated its 2002 recommendations on the screening of prostate cancer to exclude men over the age of 75.

The task force reviewed evidence-based literature on the benefits of screening, the psychological harms of false-negative PSA test results and the history of PSA-detected prostate cancer to establish recommendations. The guidelines were published in today's issue of Annals of Internal Medicine.

Though they recognize the effectiveness of PSA screening in the detection of some prostate cancers, the task force did not find enough evidence to support post-screening treatment in men younger than 75 years, compared with treatment following clinical detection.

In men over the age of 75, evidence has shown that the risks of screening for prostate cancer outweigh the benefits and, therefore, the task force recommends against it.

Potential harms associated with post-detection treatment, such as erectile dysfunction, urinary incontinence, bowel dysfunction and death, are of concern to the task force, given the number of men treated for prostate cancer who would not have developed cancer-related symptoms during their lifetime.

Recommendations for clinical practice

According to the task force, the benefits and harms of PSA testing and prostate cancer treatment should be discussed with patients and their personal preferences should be considered prior to PSA test consideration. Patients should also be aware of inconsistencies in the evidence.

Due to a lack of agreement regarding optimal treatment for prostate cancer in patients younger than 75 years, the task force recommended that disease management include watchful waiting, active surveillance, radical prostatectomy, external-beam radiation therapy and brachytherapy.

If effective, the mortality benefits of screening and treatment may not be experienced for 10 years, limiting the number of men over the age of 75 who would benefit. Men younger than 75 years with chronic medical problems and a life expectancy shorter than 10 years would also be less likely to benefit, according to the guidelines.

More data needed

To determine the effect of population-based PSA testing on prostate cancer mortality in men younger than 75 years, the task force recommends more randomized, controlled trials be conducted.

Data are needed to better indicate treatment. The task force recommends that future studies are conducted to determine testable characteristics of screening-detected prostate cancer that predict poor health outcomes.

The benefits of immediate treatment should also be compared with those of delayed treatment in men whose prostate cancer is detected by PSA screening, the task force wrote.

Ann Intern Med. 2008;149:185-191.

Click here to read comments from a HemOncToday.com blogger on the updates to the prostate cancer screening guidelines.

It is very important to understand that a large number of guidelines exist with regards to prostate cancer screening. The U.S. Preventive Services Task Force is probably the most conservative of all the groups that issue guidelines, which is an important point to recognize. They are correct in stating that evidence is lacking to determine whether treatment for prostate cancer detected by screening — as opposed to after clinical detection — improves health outcomes in men younger than age 75 years. The data as to whether or not screening improves outcomes is uncertain because no trials have addressed the point. On the other hand, the majority of physicians who take care of prostate cancer patients have themselves chosen to undergo prostate cancer screening. Further, the issue related to the treatment of prostate cancer has never been segregated (in a randomized way) into those who have been screened and those who have not. Therefore, the task force is making a conclusion based on the absence of data.

One also has to consider legal ramifications that exist for not screening and not offering screening for patients. If it represents a community standard and one does not offer screening despite the fact that other physicians in the community do, then the lack of screening and lack of communication on that issue can result in a legal liability, which has been upheld in a number of cases.

It is very clear that PSA screening can detect cancer at an earlier stage and that the probability of being diagnosed with metastatic cancer is very remote if screening occurs. The American Cancer Society guidelines recommend that the pros and cons of screening be discussed very clearly with individual patients through a process of shared decision making. Whether or not screening occurs should involve both clear communication and sensitivity to patient concerns. It is interesting that although the USPSTF makes no recommendation for screening in men under age 75 because of insufficient evidence, that in the 'suggestions for practice' section, the USPSTF makes note that clinicians should discuss 'the potential benefits and known harms of PSA screening' with their patients younger than age 75 years.

Another issue related to these guidelines is the reluctance on the part of many physicians to utilize age-related guidelines because chronologic age and physiologic age are rarely the same. The American Cancer Society states that those with a life expectancy of <10 years will experience very small, if any, benefits from prostate cancer screening. Thus, the ACS recommendations are based on life expectancy, not chronologic age.

– Oliver Sartor, MD

Piltz Professor of Cancer Research, Depts. of Medicine and Urology,
Tulane Medical School, New Orleans