Task Force to revisit prostate cancer screening recommendations

The U.S. Preventive Services Task Force (USPSTF) is inviting public comments on a draft research plan to update its 2018 recommendation statement on screening for prostate cancer. As I wrote in a previous blog post, the USPSTF’s decision to partially reverse its previous stance recommending against PSA-based screening was based on little new data. Since then, follow up of trials of localized prostate cancer treatments has shown no mortality benefits for immediate surgery or radiotherapy compared with active surveillance for 15 years after diagnosis. In the October issue of American Family Physician, a POEM on the UK ProtecT study results reports that 40 out of every 100 trial participants who selected active surveillance avoided surgery or radiotherapy, with no increase in the risk of death and a small increase in the risk of developing metastatic disease.

New questions that the USPSTF intends to review for this update involve the impact of pre-biopsy prostate cancer risk calculators or magnetic resonance imaging (MRI) on prostate biopsy rates, morbidity and mortality, quality of life, and function. A 2022 Diagnostic Tests article examined the utility of multiparametric MRI (mpMRI) for the evaluation of prostate cancer. A subsequent study found that routinely performing MRI prior to prostate biopsy in Sweden reduced biopsy rates, increased the detection of higher-grade (Gleason score 7 or higher) tumors, and decreased the detection of lower-grade (Gleason score 6) tumors. However, a UK study found that 1 in 6 asymptomatic men between the ages of 50 and 75 invited for a “prostate health check” had a prostate lesion detected on MRI, raising concern that this test may not be a panacea for reducing overdiagnosis.

The American Urological Association (AUA) updated its guidelines on prostate cancer screening and considerations for a prostate biopsy earlier this year. The AUA continues to recommend offering PSA screening every 2 to 4 years to patients aged 50 to 69 years and repeating a newly elevated PSA test before further testing, imaging, or biopsy. It gives a conditional recommendation for use of mpMRI prior to initial biopsy:

In anticipation of more definitive data, it is reasonable to obtain an mpMRI in biopsy-naïve patients prior to their first biopsy, but such a practice cannot be regarded as the standard approach based on the currently available evidence.

In the meantime, how should primary care physicians approach patients who are potentially eligible for screening? The current issue of the Annals of Family Medicine includes a scoping review on patient communication preferences for prostate cancer screening discussions. Based on an analysis of 29 studies, the researchers identified four main themes of successful discussions: using everyday language, receiving enough information, spending sufficient time, and having a trusting and respectful relationship. Notably, they found that without physician prompting, “men rarely considered possible downstream consequences if they screened positive.” Obstacles to robust screening discussions included patients having already decided to pursue screening, being passive in medical encounters, and perceiving threats to masculinity and longevity in these conversations.

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This post first appeared on the AFP Community Blog.

Coronary artery calcium is a common finding in older adults

The 2018 American College of Cardiology/American Heart Association cholesterol management guidelines advised that for patients with an intermediate 10-year atherosclerotic cardiovascular disease (ASCVD) risk (7.5% to 19.9%), a coronary artery calcium (CAC) score can be used to guide the decision to start or defer statin therapy:

If the CAC score is zero, statin therapy should be withheld or delayed unless the patient is a cigarette smoker, has diabetes, or has a strong family history of premature ASCVD. A CAC score of 1 to 99 suggests statin therapy, particularly for patients 55 years and older. If the CAC score is 100 or greater or in the 75th percentile or greater, statin therapy is indicated for any patient unless otherwise deferred by the outcome of the physician–patient risk discussion.

This recommendation to selectively incorporate CAC scoring into ASCVD risk management has been controversial; the U.S. Preventive Services Task Force (USPSTF) found insufficient evidence that adding the CAC score to traditional risk assessment improves patient-oriented outcomes. In a previous American Family Physician editorial, Drs. John Mandrola and Andrew Foy argued that “it is unclear if knowing the coronary artery calcium score would improve decision quality or adherence to statin therapy.” However, a recent Diagnostic Tests article by Dr. Hu Ying Joanna Choi concluded that “CAC score is a strong predictor of coronary heart disease, CVD, and mortality risk and provides risk discrimination and stratification beyond that provided by traditional risk factor models.”

Incidental detection of CAC on chest computed tomography (CT) scans performed for other reasons in persons without clinical ASCVD was demonstrated in a previous study to increase statin prescriptions, cardiology clinic visits, and stress tests. Until recently, however, the prevalence of CAC in asymptomatic adults was not known. Using data from the National Institutes of Health-sponsored Multi-Ethnic Study of Atherosclerosis in persons aged 45 to 84 years without ASCVD symptoms at baseline, Dr. Matthew Tattersall and colleagues calculated CAC prevalence by age, sex, race, and ethnicity. They found that across all groups, most men in their early 60s had detectable CAC, and the majority of women had CAC by their early 70s. Nearly all (96 to 98%) non-Hispanic White adults in their early 80s had CAC.

The study authors concluded the following:

[A]lthough CAC presence is associated with increased ASCVD risk regardless of age, CAC is common as age increases. Its detection provides an opportunity to discuss ASCVD risk but should avoid provoking unnecessary patient anxiety.

Further,

given the high prevalence of CAC at older ages, a finding of CAC on a CT scan should not reflexively result in a specialist referral or a prescription for a statin and/or aspirin, but rather a comprehensive ASCVD risk assessment with consideration of competing risks and patient preferences.

Clinical summaries of current USPSTF recommendation statements on statins and low-dose aspirin for primary prevention of ASCVD in adults are available on the AFP website.

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This post first appeared on the AFP Community Blog.