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Inclusion of these cohort studies would also make clear
that the 13-yr horizon to which the[26_TD$DIFF] USPSTF guideline refers
is far too short. For a 55-yr-old man, the question is
outcomes at 30 yr andmore. While the guideline reflects the
latest follow-up reported to date for the ERSPC trial, the
evidence is abundantly clear that mortality risk increases
sharply with longer follow-up, and that, by extension, the
number of lives saved rises and the numbers needed to
screen and treat fall accordingly . Randomized trials
yield valuable insights, but a new trial randomizing men
younger than 50 yr is extremely unlikely at this stage, and
avoiding contamination in a control arm in any developed
country would be pragmatically impossible. Ignoring all
nonrandomized evidence on principle yields an incomplete
picture of the knowledge base on PSA screening, and does a
large disservice to at-risk men.
This problem is particularly salient for African-Amer-
icans, men with a positive family history, and other groups
with a higher risk of lethal prostate cancer. While
acknowledging higher rates of cancer and lethal disease
in these populations, the guideline cites no screening
research outside the PLCO or ERSPC trials, both of which
involved overwhelmingly Caucasian cohorts. The call for
more research in these groups is of course appropriate, but
randomized trials will not provide the answers in any
foreseeable future, and better consideration must be paid to
cohort studies, modeling , and other complementary
sources of information, most of which would support earlier
screening in high-risk groups.
Despite explicitly excluding nonrandomized evidence in
defining benefits, the USPSTF opted to include both trials
and cohorts in measuring harms. Their choice of cohorts to
include, moreover, was far from inclusive and overempha-
sized outdated studies, thus leading to overestimation of
the harms. The inadequacy of the literature review on this
question is evident, for example, in the selection of
references for the PCOS and CaPSURE cohorts which were
over a decade out of date relative to more recent papers
. Cohorts such as PROST-QA were excluded
entirely, as were large meta-analyses and other
data sources. While there is no argument that surgery and
radiation can adversely affect urinary, bowel, and sexual
functions, the statements that one in five men need diapers
in the long term after surgery, two in three suffer long-term
sexual dysfunction, and one in six men suffer long-term
bowel complications after radiation are simply not defen-
sible in light of more contemporary data.
The new guideline reiterates a ‘‘D’’ recommendation
against any screening for men aged 70 yr. While the ratio
of benefits and harms may be different for older men—and
certainly a somewhat elevated PSA can be more difficult to
interpret in this age group—life expectancy for healthy men
at age 70 is now quite protracted, and there is a big
difference between a man who has had prior reassuring PSA
results in his 50s and 60s and one who has never been
screened before. Older men who are not treated effectively
for high-grade prostate cancer face an approximately 25%
risk of prostate cancer mortality , and conversations
with healthy men in their 70s should be more individual-
ized and nuanced than the new guideline suggests.
Finally, the USPSTF has againmissed a major opportunity
to advocate that screening efforts should focus on
identification of higher-risk cancers. The statement that
we cannot distinguish aggressive, potentially lethal cancer
frommore indolent disease ignores decades of research and
progress. In fact, prostate cancer can be risk-stratified with
approximately 80% accuracy using clinical parameters
alone , accuracy that can be further improved with
emerging imaging, genomic, and other tests.
The evidence review stated that a single investigator
abstracted all the study data . Given the massive volume
of prostate cancer research published in the past 5 yr, this
may have been an insurmountable challenge for any
individual, especially one without prior experience in
prostate cancer research. [27_TD$DIFF]In fact, the evidence review and
guideline miss many critical studies directly addressing the
priority questions identified in the Research Needs and Gaps
section. In contrast to the 2012 guideline, this time the
USPSTF actively sought informal input from four urologic
oncology experts, although none of these contributed
directly to the evidence review or final guideline.
The draft recommendation [28_TD$DIFF]closed for[29_TD$DIFF] formal comment
[30_TD$DIFF]on May 8, 2017, [31_TD$DIFF]but readers [32_TD$DIFF]can [33_TD$DIFF]certainly continue to [34_TD$DIFF]voice
their [35_TD$DIFF]opinions [36_TD$DIFF]to the [37_TD$DIFF]USPSTF [38_TD$DIFF]leadership, and [39_TD$DIFF]should
[40_TD$DIFF]continue [41_TD$DIFF]to [42_TD$DIFF]engage with their local primary care communi-
ties. Following the draft and final ‘‘D’’ recommendations in
2011 and 2012, Twitter proved to be an active forum for
debate on the subject , one monitored by many patients
and policymakers. Those with opinions on this subject are
encouraged to make their thoughts heard on Twitter and
other social media platforms using the hashtags #pcsm and
#uspstf.
The new ‘‘C’’ recommendation represents substantial
progress in the right direction towards offering men a fair
opportunity to discuss the risks and benefits of screening
with their primary care providers. [43_TD$DIFF]Hope [44_TD$DIFF]springs [45_TD$DIFF]eternal the
finalized recommendation will reflect a fairer and more
comprehensive consideration of the available evidence
base. The USPSTF should, like other guidelines panels,
formally engage stakeholders and experts with both
breadth and depth of knowledge and experience in order
to give men and their physicians the best possible guidance
on the perennially complex questions surrounding early
detection of prostate cancer.
Conflicts of interest: The author has nothing to disclose.
References
[1] Tasian GE, Cooperberg MR, Cowan JE, et al. Prostate specific antigen
screening for prostate cancer: knowledge of, attitudes towards, and
utilization among primary care physicians. Urol Oncol
2012;30:155–60
[2] Moyer VA. U.S. Preventive Services Task Force. Screening for pros-
tate cancer: U.S. Preventive Services Task Force recommendation
statement. Ann Intern Med 2012;157:120–34
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