USANZ welcomes US Preventative Services Task Force new recommendation on Prostate Cancer testing

The Urological Society of Australia and New Zealand welcomes the latest United States Preventative Services Task Force (USPSTF) draft Recommendation Statement on prostate cancer testing  which replaces its controversial 2012 guidelines which advised against testing for the disease.

The US Preventative Task Force makes recommendations about the effectiveness of specific preventative care services for patients without obvious related signs or symptoms.

Its latest statement says the decision about whether to be screened for prostate cancer should be an individual one and recommends clinicians inform men ages 55 – 69 about the potential benefits and harms of prostate-specific antigen (PSA) – based screening for prostate cancer.

The USPSTF said changes to its recommendation was “based in part on additional evidence that increased the USPSTF’s certainty about the reductions in risk of dying of prostate cancer and risk of metastatic disease.”

This included evidence from a large European trial, European Randomised Study of Screening for Prostate Cancer (ERSPC), that PSA-based screening programs in men aged 55 – 69 may prevent up to 1 to 2 deaths from prostate cancer over approximately 13 years for every 1000 men screened and  may also prevent up to 3 cases of metastatic prostate cancer per 1000 men screened over 13 years.

“This is a significant shift and we are delighted the United States Preventative Services Task Force has revised its recommendation to a position much closer to ours,” said Adjunct Professor Peter Heathcote, President of the Urological Society of Australia and New Zealand.

“The Urological Society of Australia and New Zealand always believed the USPTF 2012 position was flawed and potentially harmful.”

US Preventative Services Task Force

In 2012 USPSTF recommended against PSA testing altogether arguing  the harms outweighed the benefits.

The statement generated widespread publicity around the world and there was a  subsequent drop in PSA testing.

“We have been very concerned about the  longer term impact of a decline in PSA testing in Australian and New Zealand men and the potential consequences for those men who may have benefited from testing who either were not offered, or did not seek, PSA testing as a result of these high profile recommendations,” said Adjunct Professor Heathcote.

“We acknowledge the PSA blood test is not infallible and that previously there was over diagnosis and overtreatment of prostate cancer, but since the early days of PSA testing we have become much more sophisticated at managing the disease to ensure the best possible oncological and quality of life outcomes for men including the use of Active Surveillance for low risk disease.

“Ultimately the PSA blood test remains the best test available for detecting early prostate cancer and can be the first sign that a man is harbouring a prostate cancer that is still localised to the prostate, but that could spread and kill him if left untreated.”

New Guidelines

In 2015 a new set of evidence-based guidelines for New Zealand GPs was drafted to help end the confusion about prostate cancer testing for New Zealand men and their doctors and provide a clear, clinical pathway for testing, management and referral of men who present to primary care practitioners with prostate-related issues.

The recommendations help define which men specifically will benefit the most from testing and who should be referred for further investigation and treatment.  The aim of the guidelines is to ensure men who are unlikely to benefit aren’t unnecessarily tested or treated while ensuring those men who are at risk of life-threatening disease aren’t missed.

Importantly, the guidelines also take into account cultural sensitivities that may be a barrier to prostate cancer testing in some men, and considers age, family history, ethnicity and other demographic and lifestyle factors. Prostate cancer outcomes vary among New Zealand men, with Maori men living in rural areas having a significantly higher mortality rate from the disease.

The Prostate Cancer Management and Referral Guidance can be found at: www.health.govt.nz

 They include:

• For Men 50 – 70 years, or over 40 years with a family history of prostate cancer, GPs must obtain informed consent before testing, after discussing the benefits and risks of PSA test and/or DRE and the implications if the result from either is abnormal.
• Men with a raised PSA level should have a follow-up test after 6 – 12 weeks to confirm the result.
• However, men with a raised PSA level as well as an abnormal DRE or a “red flag” – i.e. a symptom that may indicate advanced or metastatic prostate cancer (including acute neurological symptoms, renal failure, bone pain or macroscopic haematuria) should be referred to a urological or radiation oncology service.
• A man with an abnormal DRE should be referred to a urology service.
• Men with a family history who have a normal PSA and DRE result should be offered a PSA test and DRE every 12 months from 40 – 70 years.
• Men without a family history after a normal PSA and DRE result should be reassured they are unlikely to benefit from further testing, particularly after the age of 70. Should a patient, however, request further testing it should be offered every 2 – 4 years.