EURURO Vol. 72 No. 3

326 476

Platinum Opinion
The New US Preventive Services Task Force ‘‘C’’ Draft
Recommendation for Prostate Cancer Screening
Matthew R. Cooperberg
Departments of Urology and Epidemiology & Biostatistics, UCSF Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco San
Francisco, CA, USA
In 2011, the US Preventive Services Task Force (USPSTF), the
guideline panel with the greatest influence among US
primary care providers , issued a ‘‘D’’ recommendation
regarding prostate-specific antigen (PSA)–based prostate
cancer screening[21_TD$DIFF]—asserting, in effect, that no men should
ever be offered screening[22_TD$DIFF] . This decision, finalized in
2012, reflected both critical misinterpretations of the
evidence available at the time[23_TD$DIFF], and growing impatience
with the intractable pervasiveness of overtreatment for
low-risk prostate cancer in the USA .
The ‘‘D’’ recommendation had an immediate and
significant suppressive effect on rates of both PSA screening
and prostate cancer diagnosis across the country . Per-
haps predictably, the decline in low-risk cancer diagnoses
(ie, less overdiagnosis) was matched evenly by a decline in
high-risk diagnoses, strongly suggestive of more underdi-
agnosis of potentially lethal disease . Age-adjusted
prostate cancer incidence rates are now at the lowest level
since the 1980s, and this was the first year since the dawn of
the PSA era that reported prostate cancer mortality rates
have not declined . The 2012 USPSTF recommendation
was inconsistent with most other guidelines—which
predominantly advise some variation on shared decision
making—and was highly controversial, leading, in part, to a
bill submitted to Congress to mandate that the USPSTF
include specialist expertise in its deliberations .
Last month, in a major reversal, the USPSTF issued a new
draft guideline, with a ‘‘C’’ recommendation that men aged
55–69 yr should be informed about the benefits and harms
of screening, and offered PSA testing if they choose it . For
men aged 70 yr, the recommendation remains ‘‘D’’, or ‘‘do
not screen.’’ This change is obviously a big step in the right
direction. Whether ‘‘C’’ is the correct conclusion, however,
depends heavily on the evidence [24_TD$DIFF]included to characterize
both the benefits and harms of screening, and multiple
important errors and limitations remain in this regard.
In terms of benefits, the new guideline and its
underlying evidence review state that screening men
between the ages of 55 and 69 yr will save one to two lives
per 1000 men screened within 13 yr. This conclusion is
based primarily on the most recent report from the ERSPC
trial While the guideline continues to [25_TD$DIFF]insist that the
quality of the ERSPC and the PLCO trials were both ‘‘fair’’,
the new update finally acknowledges that the latter, in
whichmore than 90% of the ‘‘control’’ participants received
at least one PSA test , was in fact a trial of opportunistic
vs. ad hoc screening rather than screening vs. no screening,
and does not attempt to adjust down the survival benefit
based on the PLCO.
The decision to exclude the Go¨ teborg screening trial ,
for which only the older subset was included in the ERSPC,
was a decision shared with the American Urology Associa-
tion guideline , [1_TD$DIFF] had the result of reducing the overall
mortality benefit observed across trials and, more impor-
tantly, prevented a level 1 evidence–based recommenda-
tion for screening men aged 50–55 yr. In fact, a growing
body of evidence from nonrandomized but very well-
characterized—and, in one case, completely uncontaminat-
ed—cohorts indicates that the use of PSA at earlier ages,
when benign prostatic hyperplasia and related processes
are less likely to drive false-positive PSA elevation, could
effectively stratify men to early detection, repeat PSA
testing, or extended deferral of further testing. Under such a
strategy[2_TD$DIFF], the majority of men tested once at 45 or 50 yr
could defer any further consideration of prostate cancer risk
for a decade or more .
available at
journal homepage:
* UCSF Helen Diller Family Comprehensive Cancer Center, University of California, Box 1695, 550 16th Street, San Francisco, CA 94143-1695, USA.
Tel. +1 415 8853660; Fax: +1 415 8857443.
E-mail address:
0302-2838/# 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.