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PHILADELPHIA, May 22, 2012 - Following a period for public
comment, the United States Preventive Services Task Force (USPSTF)
released its final recommendation for prostate cancer screening.
The Task Force now recommends against PSA-based screening for all
men, regardless of age. The final recommendations are being
published early online in the May 22 issue of Annals of Internal
Medicine, the flagship journal of the American College of
The Task Force last published recommendations on prostate cancer
screening in 2008. At the time, researchers concluded that there
was no evidence to support PSA testing for men over the age of 75.
An independent panel of experts reviewed evidence published since
2008 and concluded that the harms of PSA testing outweigh the
benefits regardless of age. The Task Force considers health
benefits and harms, but not costs, when developing
The primary goal of prostate cancer screening programs is to
save lives and prevent symptomatic disease. The Task Force
considered two major trials of PSA testing in asymptomatic men to
assess the life-saving benefits of PSA testing. The first trial,
conducted in the U.S., did not demonstrate any prostate cancer
mortality reduction as a result of screening. The second trial,
conducted in seven European countries, found a reduction in
prostate cancer deaths of about one death prevented per 1,000 men
screened in a subgroup of men aged 55 to 69 years, mostly in two
countries. Five of the seven countries reporting results did not
find a statistically significant reduction in deaths.
Strong evidence shows that PSA screening is associated with
significant harms. Nearly 90 percent of men with PSA-detected
prostate cancer undergo early treatment with surgery, radiation, or
androgen deprivation therapy. Evidence shows that up to five in
1,000 men will die within one month of prostate cancer surgery and
between 10 and 70 men will survive, but suffer life-long adverse
effects such urinary incontinence, erectile dysfunction, and bowel
According to William J. Catalona, M.D., Medical Director of the
Urological Research Foundation and author of an accompanying
editorial, the Task Force recommendation has underestimated the
benefits and overestimated the harms of prostate cancer screening.
He and his co-authors argue that the Task Force -- whose panel does
not include urologist or cancer specialists -- largely bases its
recommendations on flawed studies with inadequate follow up time.
In addition, the Task Force recommendations focus on mortality and
do not take into consideration the substantial illness related to
living with advanced cancer.
Editorial co-author, Dr. Henry Lynch, Director of the Hereditary
Cancer Center at Creighton University, adds that the Task Force
recommendations also leave out high-risk populations and younger
men. The authors express concern that the new recommendations will
take Americans back to an era when prostate cancer was often
discovered at advanced, incurable stages.
"The recommendations of the USPSTF carry considerable weight
with Medicare and other third-party insurers," Dr. Lynch said. "My
colleagues and I strongly believe that the Task Force
recommendations should not be used as justification by insurers,
including Medicare, to deny diagnosis of prostate cancer to the
male population at risk."
Yet, according to Otis W. Brawley, MD, MPH, Chief Medical
Officer of the American Cancer Society, and author of a second
accompanying commentary, overdiagnosis makes screening seem to save
lives when it truly does not. Many men are diagnosed with prostate
cancer that may never have progressed within their lifetime. Yet
because they were screened and treated, they think screening saved
"Many people have a blind faith in early detection of cancer and
subsequent aggressive medical intervention whenever cancer is
found," wrote Dr. Brawley. "There is little appreciation of the
harms that screening and medical interventions can cause."
In October 2011, the Task Force posted its draft recommendations
for public comment. At the time, the Task Force had given PSA
screening a grade "D," meaning that physicians should not offer the
test because the harms outweigh the benefits. Many people who
commented on the recommendations urged the Task Force to change the
recommendation to a grade "C," meaning physicians could provide the
test to patients who request it. However, no new evidence was
presented. The recommendation remains unchanged.
While the recommendation clearly states that physicians should
not offer PSA screening, the Task Force says it leaves the ultimate
power in the hands of the health care providers.
"The USPSTF recognizes that clinical, policy, and coverage
decisions involve more considerations than evidence alone," said
Task Force Chair, Virginia A. Moyer, MD, MPH of Baylor College of
Medicine in Houston, TX. "Clinicians and health care providers
should understand the evidence but individualize decision-making to
the specific patient or situation."
About Annals of Internal MedicineAnnals of Internal Medicine is one of the five most widely
cited peer-reviewed medical journals in the world, with a current
impact factor of 16.2. The journal has been published for 82 years.
It accepts only 7 percent of the original research studies
submitted for publication. Follow Annals on Twitter and Facebook.