After a years-long epidemic where men were treated for a cancer that might never have caused them a problem, providers are decreasing their use of the prostate-specific antigen screening test.
The number of diagnosed cases has gone down during the same period, according to two studies published Tuesday in JAMA.
But researchers are split on whether the drop in cases is the result of a 2012 recommendation by the U.S. Preventive Services Task Force that warned the benefits of the prostate-specific antigen screening test or PSA did not outweigh the harms.
“On one hand, overdiagnosis and overtreatment may be reduced in view of the substantial proportion of prostate cancer cases detected through PSA testing that would not cause harm if left undetected,” American Cancer Society researchers wrote in one of the reports. “On the other hand, less screening or discontinuing screening may lead to missed opportunities for detecting biologically important lesions at an early stage and preventing deaths from prostate cancer, the ultimate goal of screening.”
About 1 in 7 U.S. men will be diagnosed with the disease in their lifetimes. While most will die from something else, more than 27,000 are expected to die from the disease this year alone.
In 2012, the USPSTF reported that prostate cancer was the most commonly diagnosed non-skin cancer in men, but there was only a 2.8% risk of dying from the disease. It also noted that two large trials found overdiagnosis rates of 17% to 50%.
The agency, which is influential in determining what tests are paid for by the CMS, also expressed concern that men were being treated for tumors that would never reach a harmful stage. Another concern was that older men with other comorbidities were receiving aggressive treatment that had little overall benefit in terms of life expectancy.
Two years ago, both the American Urological Association and the American College of Physicians internal medicine society issued guidelines recommending against screening in most cases.
Another study, conducted by researchers at Brigham and Women's Hospital, Boston; the Dana-Farber Cancer Institute, Boston; and other institutions and also published in JAMA on Tuesday, found the 2012 USPSTF guidelines did make an impact.
The researchers found that the number of men reporting that they received the PSA test fell to 31% in 2013 from 36% in 2010. For men ages 60 to 64, however, the decrease was more significant—falling to 35% from 45%.
“Undeniably, the strategy of aggressively screening everyone, biopsing everyone, and treating everyone led to 40% fewer men dying,” said Dr. Scott Eggener, an associate professor of surgery and co-director of the prostate cancer program at University of Chicago Medicine. But, he added, it also led to overtreatment.
This problem, however, is “autocorrecting,” Eggener said. Depending on location, 40% to 60% of men are being treated with “active surveillance,” where their condition is monitored but they may not have surgery or receive radiation treatment, he said.
Eggener suggests that smarter screening is needed. For example, patients with a life expectancy greater than 10 years should be screened if they are concerned.
He worries that hard-line anti-testing forces could persuade regulators to penalize physicians who order a PSA screen, limiting access to patients, some of whom are in danger.
Another study published recently in the Journal of Urology showed that after the UPSTF guidelines were released, the diagnosis for men with high risk dropped 28.1%.
One of the authors of that report, Dr. David Penson, also wrote an editorial accompanying the two JAMA studies.
“It is time to accept that prostate cancer screening is not an 'all-or-none' proposition and to accelerate development of personalized screening strategies that are tailored to a man's individual risk and preferences,” Penson, a professor and chairman of surgery at Vanderbilt University, concluded in his editorial.
“If you do things in an extreme manner, you get extreme results,” Penson said in an interview. “But it's also not like the prostate cancer suddenly isn't there. We're just not finding it.”
The USPSTF is updating the 2012 recommendations with new guidelines expected around 2017. Public comments are being accepted until Nov. 26.
The revisions are still in development, but Dr. Douglas Owens, USPSTF member and Stanford University professor, defended the 2012 recommendations.
Owens said the task force agrees with the American Cancer Society researchers who suggest more research is needed to draw conclusions between the reduction in early stage prostate cancer diagnosis and any trends in mortality. He said further research on the effects of preventive drugs and screening methods could better distinguish between harmful and benign cancers.
A similar USPSTF controversy has played out with women. Earlier this year, the task force issued draft recommendations that women between ages 50 to 74 should have a mammogram every two years and that screening for women in their 40s should be an individual decision. The American College of Radiology and the Society of Breast Imaging said the recommendations, if adopted, could cost thousands of lives and the loss of insurance coverage for beneficiaries.
