[Richard M. Hoffman, MD, MPH, is a general internist, Professor of Medicine at the University of New Mexico School of Medicine and a staff physician at the Albuquerque VA Medical Center. He also serves as Interim Director for Cancer Prevention at the University of New Mexico Cancer Center. His areas of research interest are prostate and colorectal cancer screening and prostate cancer treatment outcomes, with expertise in clinical epidemiology, health services research, and meta-analysis. He is a medical editor for prostate cancer topics for the Foundation for Informed Medical Decision Making and works with the Foundation to develop shared decision making tools for prostate cancer screening and treatment of localized prostate cancer.]
Once again, the United States Preventive Services Task Force seems headed for a storm of controversy. The Task Force concluded that screening should be discouraged because it has no net benefit or the harms outweigh the benefits.
Not even two years ago, the Task Force's recommendation against routinely performing mammography in average-risk women before age 50 outraged professional organizations, advocacy groups, celebrities, politicians, and many other vocal critics. Unfortunately, the somewhat awkward message was distorted to imply that these women should never undergo mammography. In fact, the Task Force was highlighting that mammography for these women involved important trade-offs between potential benefits and harms--and that women needed to make informed, personalized decisions. This is an appropriate message.
However, the new recommendation on prostate cancer seems troubling. In 2008, the Task Force gave prostate cancer screening an "I" rating because the available evidence was considered insufficient to recommend for or against screening--largely because there were no valid data from randomized controlled trials of screening. The Task Force suggested that men be informed about the risks and benefits of screening, though strongly advised against screening men age 75 and older.
In 2009, long-awaited results from the major randomized controlled trials were published. The European Randomized Study of Screening for Prostate Cancer (ERSPC) found that screening reduced prostate cancer mortality by 20%. In contrast, the American Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO) found no benefit with screening. However, evaluating PSA in America was challenging because screening was so pervasive that investigators had difficulty enrolling men who had never been screened--or preventing screening in the control group. The validity of the negative PLCO results is uncertain. The ERSPC study was more credible, but showed only a small absolute survival benefit. This benefit must be balanced against the harms of overdiagnosis--finding cancers that would never cause clinical problems during a man's lifetime--and the resulting overtreatment, which can lead to urinary, bowel, and sexual dysfunction.
Unfortunately, we cannot confidently identify the "overdiagnosed" cancers found with screening, so most men will undergo surgery or radiation therapy. A new strategy of active surveillance might mitigate the harms of overdiagnosis. With this option, men are closely monitored with PSA tests, digital rectal examinations, and biopsies--and will be offered surgery or radiation only if the cancer shows signs of being aggressive.
Ideally, men should be making an informed decision that best reflects their values for the potential downstream consequences of screening. This is indeed the conclusion (based on similar clinical data) that the Task Force reached regarding mammography for women before age 50. The Task Force classified this as a grade "C" recommendation--which is what I expected for prostate cancer screening.
USPSTF's grading system Only registered and activated users can see links., Click Here To Register...
Source: HealthNewsReview
Once again, the United States Preventive Services Task Force seems headed for a storm of controversy. The Task Force concluded that screening should be discouraged because it has no net benefit or the harms outweigh the benefits.
Not even two years ago, the Task Force's recommendation against routinely performing mammography in average-risk women before age 50 outraged professional organizations, advocacy groups, celebrities, politicians, and many other vocal critics. Unfortunately, the somewhat awkward message was distorted to imply that these women should never undergo mammography. In fact, the Task Force was highlighting that mammography for these women involved important trade-offs between potential benefits and harms--and that women needed to make informed, personalized decisions. This is an appropriate message.
However, the new recommendation on prostate cancer seems troubling. In 2008, the Task Force gave prostate cancer screening an "I" rating because the available evidence was considered insufficient to recommend for or against screening--largely because there were no valid data from randomized controlled trials of screening. The Task Force suggested that men be informed about the risks and benefits of screening, though strongly advised against screening men age 75 and older.
In 2009, long-awaited results from the major randomized controlled trials were published. The European Randomized Study of Screening for Prostate Cancer (ERSPC) found that screening reduced prostate cancer mortality by 20%. In contrast, the American Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial (PLCO) found no benefit with screening. However, evaluating PSA in America was challenging because screening was so pervasive that investigators had difficulty enrolling men who had never been screened--or preventing screening in the control group. The validity of the negative PLCO results is uncertain. The ERSPC study was more credible, but showed only a small absolute survival benefit. This benefit must be balanced against the harms of overdiagnosis--finding cancers that would never cause clinical problems during a man's lifetime--and the resulting overtreatment, which can lead to urinary, bowel, and sexual dysfunction.
Unfortunately, we cannot confidently identify the "overdiagnosed" cancers found with screening, so most men will undergo surgery or radiation therapy. A new strategy of active surveillance might mitigate the harms of overdiagnosis. With this option, men are closely monitored with PSA tests, digital rectal examinations, and biopsies--and will be offered surgery or radiation only if the cancer shows signs of being aggressive.
Ideally, men should be making an informed decision that best reflects their values for the potential downstream consequences of screening. This is indeed the conclusion (based on similar clinical data) that the Task Force reached regarding mammography for women before age 50. The Task Force classified this as a grade "C" recommendation--which is what I expected for prostate cancer screening.
USPSTF's grading system Only registered and activated users can see links., Click Here To Register...
Source: HealthNewsReview
Comment