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Prostate cancer diagnosis rates significantly decrease following USPSTF guideline revision
Prostate cancer incident diagnosis rates declined 28% in the year following a U.S. Preventive Services Task Force recommendation against PSA-based screening, according to study results.
Further, significant decreases in intermediate- and high-risk disease diagnoses occurred, results showed.
“These findings suggest that reduced screening may result in missed opportunities to spare men from progressive disease and cancer death,” Daniel A. Barocas, MD, MPH, assistant professor of urologic surgery at Vanderbilt University Medical Center, said in a press release.
Daniel A. Barocas
The U.S. Preventive Services Task Force (USPSTF) issued a grade D recommendation that discouraged PSA-based screening for prostate cancer in October 2011, according to study background.
Barocas and colleagues sought to determine the impact of the USPSTF guideline recommendation on new prostate cancer diagnoses within the year following its issuance. Researchers evaluated data from the National Cancer Data Base to identify incident cancers diagnosed between January 2010 and December 2012 and to conduct an interrupted time series to observe the trend of new prostate cancer diagnoses each month before vs. after the recommendation issuance. Colon cancer diagnoses served as a comparator.
Incident monthly prostate cancer diagnoses declined 12.2% (n = 1,363; P < .01) in the month following the USPSTF recommendation. Diagnosis rates continued to drop by 164 cases per month relative to the baseline (P < .01).
Significant decreases in diagnosis occurred in all risk categories. Diagnoses of low-risk prostate cancer fell 16.9% in the first month following guideline recommendations, with immediate-risk diagnoses declining 12.9%, high-risk diagnoses declining 10.1% and non-localized disease diagnoses reduced 2.7% (P < .01 for all).
Predicted diagnoses fell 37.9% for low-risk disease, 28.1% for intermediate-risk disease, 23.1% for high-risk disease and 1.1% for non-localized disease after 1 year.
Similar decreases occurred in all subgroups of age, race, comorbidity status, income and insurance.
Comparatively, rates of colon cancer diagnoses remained constant during the observed period.
The researchers acknowledged the lack of population-based data as a limitation of their study.
“The results raise concern that if this trend continues, more men may be diagnosed at a point when their disease is advanced,” Barocas said. “Younger, healthier men with intermediate- or high-risk disease would normally be candidates for aggressive local therapy and they may not be receiving a timely diagnosis under this policy.” – by Cameron Kelsall
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Cancer strikes fear in everyone. This is especially true for patients diagnosed with advanced disease. As physicians, we all want to do something to prevent death from cancer. Why then would the U.S. Preventive Services Task Force (USPSTF) issue a recommendation in October 2011 that we should not screen for prostate cancer? A recent manuscript published in The Journal of Urology has documented that this recommendation has resulted in fewer men being diagnosed with prostate cancer and according to the lead author, has deprived younger, healthier men with intermediate- or high-risk disease from receiving timely local therapy.
While this comment may be true, it is not grounded in a careful analysis of the public health implications of screening for PSA. Barocas and colleagues note that during the past year, there has been a 37.9% decline in the number of men diagnosed with low-grade disease. Before the USPSTF recommendation, most of these men would have received treatments and many would have been rendered impotent. Few would experience increased survival. Barocas and colleagues also noted a 23.1% decline in the diagnosis of men with high-grade disease. Virtually all of these men would have received treatment, but how many would have benefited from treatment? The two published randomized trials evaluating the efficacy of surgery to cure prostate cancer — one by Bill-Axelson and colleagues and the other Wilt and colleagues — have not demonstrated a significant survival benefit over conservative management.
That leaves the men with intermediate-grade disease. Barocas and colleagues’ study suggests the incidence of intermediate-grade disease has fallen 28.1%. For these men, the SPCG-4 study shows a survival advantage especially for men under age 65. After 18 years of follow-up, the cause-specific mortality for men with intermediate-risk disease was only 15% for men undergoing surgery compared with 39% for men managed conservatively. This is the group of patients who are being deprived of potentially curative treatment. The most recent estimate from the European Randomized Study of Prostate Cancer Screening by Schröder and colleagues estimates that this represents the one patient saved from a prostate-cancer death out of the other 26 men who need to be diagnosed and managed for this disease, but who do not gain any survival advantage.
The USPSTF weighed the risks and benefits of prostate cancer screening and recognized that screening for PSA could benefit a few men, but would likely harm many more. We all want to prevent men from dying from prostate cancer, but until we can resolve the huge problem of overdiagnosis and subsequent treatment of indolent disease and improve the efficacy of treatment for those men with intermediate and advanced disease, we will likely cause more harm than good. That is the message of the USPSTF. Is it so wrong?
References:
Bill-Axelson A, et al. N Eng J Med. 2014;doi:10.1056/NEJMoa1311593.
Schröder FH, et al. Lancet. 2014;doi:10.1016/S0140-6736(14)60525-0.
Wilt TJ, et al. N Eng J Med. 2012;doi: 10.1056/NEJMoa1113162.