Prostate cancer screening made headlines again recently because of a change in the recommendations about the prostate-specific antigen (PSA) test. The United States Preventive Services Task Force (USPSTF), an independent and influential panel of experts, updated its guidance from 2012. The new guidelines, which are still in draft form as the task force seeks public comment, indicate an evolution in the panel’s thinking. Its recommendations: men ages 55 to 69 should make an individualized decision about prostate cancer screening with their doctors.
“These new guidelines acknowledge prostate cancer screening is a personal medical decision, not just a public health decision,” says Sean Cavanaugh, MD, Radiation Oncologist, at Cancer Treatment Centers of America® (CTCA) near Atlanta, Georgia. “The USPSTF wants men to know their options for prostate cancer screening and have that discussion with their doctors.”
About 161,000 men in the U.S. will be diagnosed with prostate cancer this year, according to the American Cancer Society, The average age at the time of diagnosis is 66. The USPSTF advises against PSA-based screening for men over 70. The panel had no new recommendations for men at higher risk for prostate cancer, including African-American men and men with a family history of the disease.
Changes From Past Screening Recommendations
In 2012, the task force made a controversial recommendation—advising most men not to get screened for prostate cancer using the PSA test. Recent studies show that PSA screening rates have declined substantially in the United States since then. “The original problem was not that men were finding out they had cancer,” says Dr. Cavanaugh. “The original problem was when they found out, the medical community and the patients were overreacting. That led to treating a lot of the disease that didn’t need to be treated and causing a lot of harm.”
For years, experts have disagreed on if, and when, men should be screened for prostate cancer. Screening typically involves a PSA exam. Results with an elevated PSA can be a sign of prostate cancer—but an elevated PSA can also be caused by other conditions, like inflammation of the prostate or enlarged prostate. Historically, men with elevated PSA levels were given biopsies. A positive biopsy usually resulted in treatment. But treatment for prostate cancer, including surgical removal of the prostate and radiation, is associated with incontinence and erectile dysfunction.
“By treating most of the men who were diagnosed the medical community was spending an enormous amount of money and hurting many men’s sexual health and urinary health,” says Dr. Cavanaugh. “Now with our new tools and these new guidelines, physicians can identify the men who can really benefit from treatment, while making a commitment not to treat the men who we don’t think will benefit.”
Innovations in Prostate Cancer Screening, Testing and Treatment
Those new tools include genomic testing of tumors to see if the cancer is aggressive and three-dimensional imaging, known as multi-parametric MRI, which allows doctors to monitor the entire prostate and helps guide decisions on treatment options. Keeping a close eye on the cancer through regular blood tests and digital rectal exams is known as active surveillance. Researchers have found active surveillance of prostate cancer is just as effective as more aggressive treatments for low-risk men with early stage disease.
Dr. Cavanaugh says the discussion between men with positive prostate cancer biopsies and their physicians should change as well. “It should start with whether the cancer needs to be treated at this time,” he says. “For patients at very low risk and low risk of the cancer spreading, the conversation should not begin with how are we going to treat it? It should include alternatives to definitive therapy—with the lowest chance of hurting or harming their quality of life. Then for the higher risk patients, the conversation can go straight into what the treatment options are. But by starting the conversation by asking if it should be treated at all, trust is gained and over-treatment may be avoided.”