Recent Updates in the Prostate Cancer Screening Controversy

Author: R. James Yu, MD, Urologic Oncologist

Any discussion of men’s health these days must include the topic of prostate health, particularly prostate cancer. It remains the second most common cancer, and the second leading cause of cancer death in American men. However, it remains controversial whether patients should continue to receive PSA blood test screening for this potentially serious disease. While prostate cancer deaths have declined tremendously since the introduction of the blood test in the 1980’s, PSA screening also identified non-lethal cancers that never posed a health risk to the patient in the first place. Their treatment often led to problematic, unnecessary side effects. Therefore, in 2012, the US Preventive Services Task Force (USPSTF) issued its recommendations against the use of regular PSA screenings to detect prostate cancer. As a result of its research, the task force concluded that routine PSA screening “has no net benefit or that the harms outweigh the benefits” and gave it a “D” rating, discouraging its use. Since 2012, this recommendation has led to a significant 20-25% decline in nationwide screening in men. The impact of this decline is yet to be determined, which is why I’d like to bring you up to date on the latest developments.

Paramount to the USPSTF’s decision was the results of the PLCO Trial, where US men screened with annual PSA testing were compared to men who did NOT receive testing (control arm). The trial showed no difference in prostate cancer deaths, and concluded that PSA screening added no benefit, while potentially causing significant harm. At the time, a major criticism of this trial related to the degree of PSA testing in the control arm, estimated at 50%. However, in a follow-up survey of patients in the trial, published in NEJM May 2016, investigators discovered that more than 90% of men who were not supposed to receive any testing actually received at least one PSA test during the study. In essence, this finding changes the trial to a comparison of annual screening versus occasional screening, which explains the lack of survival benefit for the PSA test. This, in addition to more published data in the aftermath of its “D” recommendation, is prompting the USPSTF to re-evaluate the role of PSA screening again. The government agency recently published a research plan on how it plans to evaluate the data, and has solicited feedback from a coalition of physician and patient groups. New recommendations are due out in 2017.

Other troublesome studies were recently presented at the 2016 Genitourinary (GU) American Society of Clinical Oncology (ASCO) conference that show as fewer men are undergoing prostate cancer screening, the cancers found were more aggressive and further advanced. Since 2012, there has been a progressive annual rise in aggressive prostate cancers detected. These cancers are being discovered later in their evolution, and the likelihood of cure decreases substantially. It is estimated that the death rates from prostate cancer will increase by about 5%. Anecdotally, this same pattern has been reflected in our patients at North Bay Urology over the same time period. We have undeniably noticed more patients with higher grade and more advanced disease at the time of diagnosis and treatment. While it was predicted that it would take 5-10 years before the impact of the USPSTF’s recommendations was fully appreciated, the urology and oncology communities are fearful that the effects are already becoming noticeable. 

However controversial, the USPSTF’s recommendations did open an important debate that had positive influences.

  • More patients are discussing with their physicians the pros and cons of screening, factoring in their own personal risk factors.
  • It lowered the number of patients diagnosed with insignificant cancers, thus saving them from harmful treatment side effects.
  • It contributed to new advances in screening technologies, and patient risk-stratification tools.
  • Newer treatment options allow more men to realize the benefit of prostate cancer screening while minimizing the harm to them.

As I first wrote in this column last year, patients should be fully informed of the pros/cons of proceeding down the path of cancer screening AND the pros/cons of NOT proceeding down that path, and make a decision for themselves. Be aware that this debate is constantly changing. The devastation seen in the past without any screening may have swung the prostate cancer pendulum towards over-diagnosis and overtreatment in prior years. However, with ongoing developments, the hope is the pendulum swings back to the point where we only target the men that truly need to be saved, while minimizing the collateral damage during that process.