Anti-PSA Screening Advice Worsens Prostate Cancer Outcomes?

Advanced prostate cancer incidence and associated mortality rates have been increasing in California since the 2010s, according to the authors of a new study.

These concerning trends may be partly driven by US Preventive Services Task Force (USPSTF) recommendations against routine prostate-specific antigen (PSA) screening, reported lead author Erin L. Van Blarigan, ScD, of the University of California San Francisco (UCSF), and colleagues.

How Have USPSTF Recommendations for PSA Screening Changed Over the Years?

“The potential benefits and harms of PSA screening have resulted in fluctuating screening guidelines over the last 20 years,” the investigators wrote in JAMA Network Open.

In 2008, the USPSTF advised against PSA screening for men older than 75 years. By 2012, this recommendation was expanded to all men, discouraging PSA screening across the board. In 2018, the guidelines called for a more individualized approach, advising men aged 55-69 years to discuss the potential benefits of and risks for PSA screening with their clinician.

“It is unclear the extent to which shared decision-making is taking place and if population groups at higher risk of prostate cancer mortality (eg, non-Hispanic Black males) are being referred for screening,” Van Blarigan and colleagues wrote. “Thus, close monitoring of cancer surveillance data is needed to understand how the changing screening guidelines have impacted the incidence and mortality of prostate cancer across population groups.”

What Did the New Study Find?

The present cohort study analyzed trends in prostate cancer incidence and mortality in California from 2004 to 2021 using data from the California Cancer Registry, the California Department of Public Health’s Center for Health Statistics, the National Cancer Institute (NCI)’s Surveillance, Epidemiology, and End Results (SEER) program, and the US Census.

Between 2004 and 2021, 387,636 prostate cancer cases and 58,754 prostate cancer deaths were recorded in California. The incidence of distant-stage prostate cancer increased by an average of 6.7% per year from 2011 to 2021.

Annual percentage change was 6.5% among Asian American, Native Hawaiian, and Pacific Islander men (2011-2021); 6.9% among non-Hispanic White men (2010-2021); 7.4% among non-Hispanic Black men (2013-2021); and 8.0% among Hispanic men (2014-2021). Due to insufficient data, trends could not be calculated for American Indian or Alaska Native men.

Prostate cancer mortality declined by 2.6% per year from 2004 to 2012 and then plateaued between 2012 and 2021. This plateau was observed across all racial and ethnic groups and regions.

Were Trends Driven By 2012 USPSTF Recommendation Against PSA Screening?

“The change in [USPSTF] guidelines to recommend no PSA screening contributed, at least in part, to the rapid increase in advanced prostate cancer,” Van Blarigan said in a written comment.

Sophia Kamran, MD, radiation oncologist at Massachusetts General Hospital and assistant professor of radiation oncology at Harvard Medical School, both at Boston, supported this hypothesis.

“I do think that the 2012 USPSTF recommendation against prostate cancer screening contributed to the rise in advanced prostate cancer cases and the plateau in mortality rates in this California-based study,” Kamran said in a written comment.

She noted that these trends echo her own study published in JAMA Network Open in 2022. Kamran’s findings, based on nationwide data, also included a “dramatic increase” in metastatic prostate cancer diagnoses, “which likely explains the increase in prostate cancer–specific mortality observed,” she said.

Scott Eggener, MD, director of the High Risk and Advanced Prostate Cancer Clinic at the University of Chicago Medicine, Chicago, who has also published on the topic, said the 2012 USPSTF recommendations “almost assuredly” contributed to present findings; however, he went on to highlight some benefits unmentioned by Van Blarigan and colleagues in their publication.

“The fuller picture is the 2012 recommendations simultaneously lowered the number of men who underwent unnecessary screening, secondary testing (MRIs and biopsies), unnecessary diagnoses, and treatment of early-stage prostate cancer,” Eggener said in a written comment. “Consequently, there were fewer men experiencing unnecessary stress, anxiety, or treatment-related side effects. This group who benefited from the recommendation is significantly larger than those who were harmed by the recommendation.”

Van Blarigan emphasized that while changes in screening guidelines have been a primary focus, the study provides a broad overview of prostate cancer trends that requires further investigation. She highlighted the need for follow-up research to explore other potential factors driving the increase in advanced prostate cancer, particularly in regions with significant variation.

Will USPSTF Call for Shared Decision-Making on Sreening Reduce Advanced Cases and Deaths?

“I think that the recommendations [for shared decision-making] are moving in the right direction but do not go far enough,” Kamran said.

It remains unclear whether clinicians are initiating discussions about screening or, more likely, that patients must advocate for themselves, she said. Even if the subject is broached, she added, adherence to varying screening guidelines can be challenging.

Eggener offered a similar view, noting that “vast numbers” of primary care providers do not offer PSA screening, even for high-risk individuals. “Shared decision-making is laudable and sensible,” he said. “Unfortunately, true shared decision-making is time-consuming, confusing, and rarely done.”

Kamran also pointed out that these dialogues are more common among certain demographics. “We will continue to see disparities exist, particularly among underserved populations,” she said.

How Can Doctors Improve Prostate Cancer Outcomes Without Overtreating?

“I think we should be mindful of the tools we have at our disposal and take advantage of having the availability of PSA for prostate cancer screening,” Kamran said. “However, the screening should be thoughtful, and action should not be taken on any one isolated screening result.”

Instead, Kamran called for screening that incorporates multiple datapoints, including PSA trajectory, prostate MRI, family history, and genetic testing when appropriate. Other assays, such as the 4Kscore and prostate health index, can help guide biopsy decisions, she added, noting that only patients with clinically significant disease should ultimately undergo treatment.

The cancer incidence data in this study was collected with support from the California Department of Public Health, the Centers for Disease Control and Prevention’s National Program of Cancer Registries, and the NCI’s SEER Program through contracts with UCSF, University of Southern California, and the Public Health Institute. Van Blarigan and Gomez reported receiving grants from the NCI. Matthew R. Cooperberg, MD, MPH, reported receiving personal fees from AstraZeneca, Pfizer, and others. Stacey A. Kenfield, ScD, reported receiving consulting fees from Fellow Health. Kamran reported no conflicts of interest.