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Is PSA now “OK”? What the task force really said about the evidence on prostate cancer screening

Is PSA now “OK”? What the task force really said about the evidence on prostate cancer screening

Reading the headlines on the US Preventive Services Task Force’s (USPSTF) update to its prostate cancer screening guidelines, you might come away with the idea that the task force has completely reversed its 2012 recommendation against broad-based prostate-specific antigen (PSA) screening.

But that would be the wrong impression.

What the revised guideline does is make a slight change. It changes the recommendation for routine prostate cancer screening from a “D” (which discourages the service since “There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.”) to a “C (which means that physicians should “Offer or provide this service for selected patients depending on individual circumstances,” and that “There is at least moderate certainty that the net benefit is small.”)

The main point is that men who are candidates for testing (ages 55 to 69) should discuss the benefits and harms of the test with their doctors and make a personal decision about whether to take it.

Some news outlets engaged in grade inflation

HealthNewsReview.org contributor Saurabh Jha, MBBS suggested, somewhat cheekily, that some urologists might want to temper their jubilation over this modest adjustment:

USPSTF gave PSA screening Grade C. Urologists are happy. But no Indian parent would be pleased unless Grade A.

— Saurabh Jha (@RogueRad) April 11, 2017

The prize for most misleading framing of this news comes from the Washington Post whose headline proclaimed: “The federal panel that opposed prostate cancer screening just changed its mind.”

Upgrading from an atrocious “D” to a mediocre “C” grade wouldn’t strike most people as much of an about-face. Yet headline-skimmers might conclude that the task force is now offering a ringing endorsement of PSA testing.

Further down in the WaPo piece, it becomes clear through very thorough reporting that this isn’t as much of a “turnaround” as the initial framing suggests, and that “the balance of benefits and harms is still close,” as one task force member puts it.

But when the WaPo story was picked up in my local newspaper, The Minneapolis Star Tribune, the headline morphed even further off message.

 

Prostate screening “OK’d”? That headline is definitely not OK.

Nor was AP’s slightly better take: “Prostate cancer tests are now OK with panel, with caveats.”

The New York Times headline, “Discuss prostate screening with your doctor, experts now say,” makes it sound like talking with your doctor about this is a new idea or a reversal.  It isn’t.

It was also a bad idea to lead, as NBC did, with the claim that “The controversial PSA blood test can save some men’s lives from prostate cancer.”

As Vinay Prasad, MD, points out in this opinion piece in STAT, saving lives from prostate cancer is not the same as saving lives.

In my mind, the greatest misconception about the test is that we say it “saves lives” when that is uncertain. PSA testing reduces the risk of dying of prostate cancer, but there is no evidence it reduces the risk of dying.

How can that be the case? Prasad explains:

Overdiagnosis and overtreatment are common with PSA screening — the USPSTF says it happens in 20 percent to 50 percent of men diagnosed by screening — so even small harms may counteract any benefits of screening. For instance, some treatments for prostate cancer, such as radiation therapy, can increase the risk of getting a second cancer.

STAT’s news coverage of the update provides a nice breakdown of the numbers that includes a discussion of benefits and harms. It’s self-consciously designed to “help you avoid whiplash” that might be induced by other headlines emphasizing reversal. However, the STAT Morning Rounds newsletter claimed, “For men between 55 and 69, the panel is punting the decision to doctors,” which is a harsh characterization of the panel’s announcement. The task force made a clear call for shared decision-making discussion between men and their doctors – a two-way deliberation between partners – a far cry from punting the decision to doctors.

“Bottom line: 1,000 men screened, one prostate-cancer death averted [over a period of 10 to 15 years],” the piece concludes.

The evidence on screening has actually changed very little

Richard Hoffman, MD, MPH, professor of internal medicine and epidemiology at the University of Iowa Carver College of Medicine/Iowa City VA Medical Center, suggests the new guideline calls for “informed screening” and emphasizes that men do not necessarily need treatment for a PSA-detected cancer.

That’s one aspect of the story that many outlets seemed to do a nice job with. The AP, for example, said “Newer research also has shown benefits from ‘active surveillance’ of men whose initial PSA tests and biopsies indicate slow-growing cancer that hasn’t spread… This approach includes repeated PSA tests and close monitoring, which can delay or even avoid the need for treatment.”

Will the new guideline have an impact? Hoffman predicts it will. It’s true that the USPSTF recommendations carry a lot of weight. After the 2012 guidelines were released, screening rates went down and so did diagnoses of prostate cancer, according to a report in JAMA.

Some medical and patient advocacy groups are embracing the new guidelines, and getting some licks in at the USPSTF at the same time. The American Urological Association  (AUA), whose members perform the prostate surgeries that often result from an elevated PSA test, has hailed the changed grading (from D to C) as the result of “a more inclusive and transparent process” — referring to political pressure put on USPSTF to include urology specialists in its deliberations.

But it takes no special expertise in prostate surgery to evaluate the evidence on screening outcomes, and Hoffman characterized the AUA’s insinuation of bias as unfair. The USPSTF has always been objective in its recommendations, he said, adding: “when new evidence becomes available they reassess.”

Be warned, the new evidence may be flawed, too

The Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial  formed the basis for earlier thinking that PSA testing offered no benefit. However, that study was later dismissed as flawed since about 90 percent of the control group had been screened, rendering the results unreliable.

The new evidence considered by the USPSTF has problems of its own, Hoffman warns. The UK’s ProtecT trial, for example, included patients who had intermediate-risk prostate cancers and would not be considered candidates for active surveillance in the US, Hoffman said. In the US, we’re still trying to determine how to best identify and monitor men with low-risk cancers.

The ProtecT trial may not be a good foundation for making broad recommendations about these patients.

As we continue to wait for longer term, applicable studies assessing the benefits and harms of routine cancer screening and active surveillance, it’s a certainty that the national discussion about prostate cancer screening is far from over.

Editor’s note: A paragraph has been added to this post to include more details about the Washington Post’s reporting on the updated guidelines.

 

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