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.