The influential US Preventive Services Task Force (USPSTF) recently announced a backtrack on its 2012 controversial stand on recommending against using the PSA (prostate-specific antigen) blood test to screen men of any age for prostate cancer.
The taskforce’s new policy, which brings it closer to the New Zealand guidelines, is that men aged 55 to 69 years should make individual decisions about whether to undergo PSA based screening for prostate cancer after discussing the potential benefits and harms of screening. But the taskforce continues, as does New Zealand, not to recommend PSA-based screening for prostate cancer in men over 70 years old.
The about-turn by the major US-Government-funded body that influences which services American health insurers fund is seen as a positive step for New Zealand by Graeme Woodside, the chief executive of the Prostate Cancer Foundation of New Zealand.
“Clearly the earlier decision of the taskforce discouraged screening and it had the effect in New Zealand of discouraging some GPs from being proactive in having their male patients tested for prostate cancer,” said Woodside. “And they used it as evidence that they didn’t need to unless there were symptoms.”
He hoped that news of the change of heart, which has had little to no coverage in New Zealand, would be picked up by GPs here and they would be more proactive in testing men in the relevant age groups.
Professor Peter Gilling, a leading urologist and researcher in prostate health, said the US taskforce’s recommendations were now more in line with what has been recommended by both the Urological Society of Australia and New Zealand (USANZ) and the Ministry of Health’s 2015 guidelines (Prostate Cancer Management and Referal Guidance).
“We are pretty pleased that America is now back in line with what we’ve been saying all along,” said Gilling. He said New Zealand’s guidelines were sound, had a good balance between over-testing and under-testing, and ensured the patient was informed.
The New Zealand guidelines, endorsed by USANZ and the Prostate Cancer Foundation, recommend discussing the benefits and risks of PSA testing with men presenting with prostate-related concerns aged between 50 to 70 (or over 40 if they have a family history).
“What the New Zealand guidelines essentially rely on is a man raising the issue with his GP, rather than the GP raising the issue with the man,” says Woodside. “And we think that is a significant fault in the New Zealand guidelines. We think there should be a much more proactive approach by GPs to men who are in the target age range [50-69 or 40-plus if a family history] to at least establish a baseline PSA reading so it could be monitored in the future.”
He said the US recommendation was an improvement on their 2012 recommendation, with reports coming out of the US indicating that the negative recommendation had led to prostate cancer screening decreasing and more men being diagnosed with more advanced disease. “When the whole point of testing is to find prostate cancer early so it can be effectively treated and men’s lives are not put in jeopardy.”
The new US decision was published in JAMA (The Journal of the American Medical Association) and the taskforce said it followed reviewing the evidence on the benefits and harms of PSA-based screening for prostate cancer, including three very large randomised- control screening trials, and commissioning a review on the over-diagnosis rate resulting from PSA screening.
The US Preventive Services Taskforce’s revised decisions were based on the following findings:
- Adequate evidence from randomised clinical trials show that screening programmes in men aged 55 to 69 may prevent about 1.3 deaths from prostate cancer over about 13 years per 1000 men screened.
- Screening programmes may also prevent about three cases of metastatic prostate cancer per 1000 men screened.
- Potential harms of screening include frequent false-positive results and psychological harms.
- Harms of prostate cancer treatment include erectile dysfunction, urinary incontinence and bowel symptoms.
- It concludes that for men aged 55 to 69 years the decision to undergo periodic PSA-based screening for prostate cancer should be an individual one after discussing the potential benefits and harms of screening with their clinician.
- “Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men.”
- “However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications such as incontinence and erectile dysfunction.”
- It also concluded with “moderate certainty” that that the potential benefits of PSA-based screening for prostate cancer in men 70 years and older “do not outweigh the expected harms” so it recommended against screening in this age group.