Data suggest ‘potential overuse’ of prostate cancer screening

Studies that suggest prostate cancer screening is overused is nothing new; however, the study by Berkowitz and colleagues might be the first time these findings have been found across the entire United States.

Part of the problem is that Americans have the unique belief that screening is important, but in many instances the benefits do not outweigh the risks. I am not an anti-screener, but when we look at things like mammography screening, colon cancer screening and lung cancer screening, people tend to see benefit and totally ignore the harms or drawbacks.

One study showed that screening 1,000 men aged 55 to 69 years over a 12-year period for prostate cancer leads to 100 men being diagnosed with prostate cancer and four dying from prostate cancer. The study also showed that if you take the same 1,000 men and do not screen them regularly, 60 will be diagnosed with prostate cancer over that 12-year period and five will die from the disease. Another study found that not screening for prostate cancer resulted in five deaths for each 1,000 men and screening resulted in four deaths for each 1,000 men. In other words, one out of the 1,000 benefited from screening.

I would let male patients know the benefits and risks to prostate cancer screening in tandem with information that is specific to them, such as their age, overall health and life expectancy, so the patient can make an informed decision. The USPSTF, American Society for Clinical Oncology, American College of Preventive Medicine, ACP and the American Academy of Family Physicians are among the many organizations that call for that informed decision-making. The wording I like the best is from the American Urological Association, which states “given the uncertainty that PSA testing results in more benefit and harm, a thoughtful and broad approach to PSA is critical. Patients need to be informed of the risks and benefits of testing before is undertaken. The risk of over detection and over-treatment should be included in this discussion.”

Berkowitz and colleagues analyzed variations in PSA screening according to geographic area and subject age in the [Behavioral Risk Factor Surveillance System]. I feel that some of their conclusions require better framing.

As I have recently pointed out, prostate cancer screening is substantially more beneficial than generally recognized. This is largely because many recommendations, such as those of the USPSTF, use very short intervals from the start of screening to calculate the harms and benefits (eg, 13 years), while many men who start prostate cancer screening will live much longer than that. Now that we have data from randomized trials and from modeling of the longer-term tradeoffs of screening, I believe recommendations need to reflect this. In my opinion, the tradeoffs suggest otherwise healthy men should undergo at least baseline PSA screening. Berkowitz and colleagues also point to stopping screening at age 70 as an indicator of quality. I would suggest that the age to stop screening is unclear and is likely aged 70 years and older in many men. This is supported by guidelines that the authors allude to.

For instance, the American Urological Association guidelines currently state “the panel does not recommend routine PSA screening in men age 70+ years or any man with less than a 10- to 15-year life expectancy. (Recommendation: Evidence Strength Grade C). Some men age 70+ years who are in excellent health may benefit from prostate cancer screening.” The National Comprehensive Cancer Network recommends discussion of PSA screening in patients aged 45 to 75 years, and in select very healthy patients with no comorbidity aged 75 years and older. Certainly, the patient’s prior PSA and comorbidities should play into the decision to screen, and at what interval, in this age group. We should certainly not dismiss any PSA testing in men aged 70 years and older as ill-advised. Testing in these men may very well reflect excellent clinical judgement by their doctor depending on their health and prior PSAs and is supported by guidelines. I would also note that Berkowitz and colleagues cite the American Cancer Society recommendations. These have not been updated since 2010, so likely do not reflect the current state of the data but are being updated soon.

Finally, I think it’s important to point out that many men, in any age group, do not require an annual PSA test — and that the screening interval should be tailored according to their prior PSA, age, as well as information we can now obtain from other biomarkers when appropriate