RSS Feeds
Are Age-Based Criteria the Best Way to Determine Eligibility for Prostate Cancer Screening?
- Ned Calonge, MD, MPH;
- Diana B. Petitti, MD, MPH; and
- Kenneth W. Lin, MD
- From Colorado Department of Public Health and Environment, Denver, CO 80246; Keck School of Medicine, University of Southern California, Los Angeles, CA 90089; and Agency for Healthcare Research and Quality, Rockville, MD 20850.
IN RESPONSE:
We appreciate the letters from Drs. Konety and colleagues and Dr. Gogol regarding the USPSTF's updated recommendation on screening for prostate cancer (1). The USPSTF recommended against screening men age 75 years or older.
First, it is important to emphasize that a systematic review conducted in collaboration with the USPSTF (2) identified no direct evidence (that is, evidence from randomized trials) that permitted the USPSTF to determine whether prostate-specific antigen screening has a net benefit on mortality for men of any age. Although some men may benefit from earlier detection of potentially fatal cases of prostate cancer, others will be harmed by the adverse effects of detection and treatment of seemingly abnormal prostate cells that would never have caused clinical symptoms. We will not know whether the uncontrolled experiment that began in the early 1990s of screening millions of men for prostate cancer has, on the whole, increased or shortened life expectancy until ongoing randomized trials are completed.
In concluding with moderate certainty that the harms of screening men age 75 years or older outweigh the benefits, the USPSTF relied on information about the natural history of clinically detected prostate cancer from a randomized trial comparing the outcomes of radical prostatectomy with watchful waiting (3). This trial suggested that the interval required to experience a mortality benefit from prostate-specific antigen screening is greater than 10 years. Even assuming that every case of prostate cancer detected by screening is potentially fatal (not true) and that treatments are never fatal (also not true), the majority of men age 75 years or older would experience no benefits from screening.
Recently published data from the trial by Bill-Axelson and colleagues (4) suggest that the USPSTF may have set the screening “cut-off” age conservatively. In the trial, men older than 65 years who underwent prostatectomy had the same mortality rate as men who did not (4).
Dr. Konety asserts that older men who are found to have “low-risk” prostate cancer could choose to enter active surveillance rather than undergo treatment, thus reducing the harms associated with prostate cancer screening. In practice, potentially lethal prostate cancer cannot be reliably identified. Because most men desire to remove all traces of cancer, attrition rates from studies of active surveillance have been high, rendering the effectiveness of the surveillance protocol uninterpretable (2). In addition, there is no evidence that active surveillance itself leads to more benefits than harms.
Ned Calonge, MD, MPH
Colorado Department of Public Health and Environment
Denver, CO 80246
Diana B. Petitti, MD, MPH
Keck School of Medicine, University of Southern California
Los Angeles, CA 90089
Kenneth W. Lin, MD
Agency for Healthcare Research and Quality
Rockville, MD 20850
Article and Author Information
-
Potential Financial Conflicts of Interest: None disclosed.
