How Did the USPSTF Arrive at This Recommendation?
Prostate Cancer: Screening
May 11, 2012
Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.
|Table of Contents|
What the USPSTF Recommendation Means for Me
- What does this recommendation mean for the average man?
- How should I decide whether to have a PSA screening test?
- Who does this recommendation cover?
- What are the risk factors for getting prostate cancer?
- I am an African American man. What does this recommendation say I should do?
- One of my family members died from prostate cancer. Should I get screened?
Discussing the USPSTF Recommendation With My Doctor or Nurse
- Should I talk to my doctor about this recommendation?
- What should I say to my doctor?
- My doctor says I need a PSA screening test. Should I get one?
The Evidence About Prostate Cancer Screening
- What are the benefits of screening?
- What are the harms of screening?
- New research has recently been released on prostate cancer. Did the Task Force take these studies into consideration?
- The number of prostate cancer deaths in recent years has declined. Why is this? Can that decline be attributed to screening?
- Where can I learn more about prostate cancer screening?
About the Task Force and Its Process
- Has anything changed since the draft recommendation?
- I submitted a comment on the draft. How do I know the Task Force saw it?
- Were any urologists involved in the development of this recommendation?
- What do other organizations recommend about prostate cancer screening? Did they collaborate with the Task Force?
- How does the Task Force make a recommendation?
- Who are the Task Force members?
Until we have a better test and better treatment options, based on a comprehensive review of the science, the USPSTF recommends that men not get the PSA test to screen for prostate cancer. Whether or not to be screened is a decision each man should make once he understands the facts and based on his own values and preferences. The USPSTF encourages you to learn more, and if you have questions to have a conversation with your nurse or doctor.
To learn more about the benefits and harms of prostate cancer screening, see the USPSTF fact sheet (PDF File, 98 KB; PDF Help) read more below, or read the full USPSTF evidence reviews, which may be found on the Task Force's Web site at https://www.uspreventiveservicestaskforce.org/uspstf/UpdateSummaryFinal/prostate-cancer-screening1.
You should know what the science says about PSA screening: There is a small potential benefit and there are significant potential harms. But you should also think about your personal beliefs and preferences for health care. Weigh the potential benefits and harms of PSA screening and decide what is most important to you. If the possibility, however small, of avoiding death from prostate cancer is more important to you than the risk of unnecessary harms, then screening may be the right decision. If you still have questions about the recommendation, the science, or your own balancing of the potential risks and expected harms, find a clinician who can help you understand the science and make a decision that reflects your values and preferences.
This recommendation is for adult men of all ages. It does not apply to men who have been diagnosed with or are being treated for prostate cancer.
Older men, African American men, and men who have a family history of prostate cancer have an increased risk of developing prostate cancer.
Currently, available evidence does not allow us to know with certainty whether the balance of benefits and harms is different for African American men. While there is not extensive evidence on the benefits of screening in African American men, the Task Force found no reason to believe that African American men have a different balance of benefits and harms from PSA-based prostate cancer screening than Caucasians. African American men might experience more benefit but also greater harms.
If you think you are at high risk for prostate cancer and want to know more about PSA screening, talk to your doctor about your individual considerations regarding the disease in comparison to the risks of screening.
The Task Force understands that this can complicate the decisionmaking process because a family history of the disease can put a man at higher risk of developing prostate cancer. There is not extensive evidence on the benefits of screening for higher-risk men, but the Task Force found no reason to believe that they are more likely to benefit from PSA-based screening, or any less likely to be harmed by it.
If you are concerned about your individual risk and wonder if PSA screening might be right for you, talk with a trusted doctor or nurse. Think about your personal beliefs and preferences for health care. Learn about scientific recommendations, like this one from the Task Force. Weigh the potential benefits and harms of PSA screening and any treatment that may result. If you choose to get a PSA test, talk with your physician about the results of your test and whether further testing or treatment is right for you.
While the USPSTF discourages the use of screening tests when the harms outweigh the benefits, it recognizes that PSA screening is a common practice today. The Task Force understands that some men will continue to request screening and some doctors will continue to offer it.
If you would like to learn more about how this recommendation applies to you individually, talk to your doctor or nurse about the recommendation, the benefits and harms of screening, and your individual risk factors for prostate cancer. You should expect a balanced discussion about the possibility of benefit and the risk of harms. Before your physician orders a PSA test or you request one, it is imperative that you discuss the issue fully and make an informed decision in partnership with your clinician.
Before speaking with your clinician about this recommendation, read the consumer fact sheet (PDF File, 165 KB; PDF Help) and the recommendation statement.
If you still have questions about how this recommendation affects you and your health, the USPSTF encourages you to discuss the recommendation with a trusted physician. You should prepare any questions you have in advance and be ready to answer questions about your health, your personal values, preferences, and goals for health, and on any history of prostate cancer in your family.
The Task Force states physicians should not recommend PSA screening for prostate cancer because the science shows that the very small possibility of a benefit does not outweigh the known risk of harms.
Before recommending this test, physicians should first ensure that you understand the very small possibility of avoiding death from prostate cancer as a result of PSA screening and the much larger risk of harm that accompanies diagnosis and unnecessary treatment. The test should be done if, and only if, as an informed patient you choose to be screened.
A man should feel comfortable deciding for himself to decline PSA screening if he does not want to take the risk.
The main goal of a cancer screening test is to reduce the number of deaths from the disease. The Task Force found that the reduction in prostate cancer deaths from PSA screening is at most very small. A large U.S. study showed no benefit from screening. A large European study that found the highest reported benefit suggests that no more than 1 man in 1,000 avoids death from prostate cancer because of screening. Other studies found no benefit at all.
The Task Force found that PSA screening has important potential harms. The PSA screening test often suggests that prostate cancer may be present when there is no cancer. This is called a “false-positive” result. Such results cause worry and anxiety and can result in follow-up tests and procedures, such as biopsies, that aren't needed. Biopsies can cause harms such as fever, infection, bleeding, urinary problems, and pain. A small number of men will be hospitalized because of these complications.
Because there is so much uncertainty about which cancers need to be treated, almost all men with prostate cancer found by the PSA test now get treatment with surgery, radiation, or hormone therapy. Many of these men do not need treatment because their cancer would not have grown or caused health problems even without treatment. This is called “overtreatment.”
The Task Force found that the treatment of cancers found by the PSA test has important, often lasting harms:
- Erectile dysfunction (impotence) from surgery, radiation therapy, or hormone therapy;
- Urinary incontinence (leakage of urine) from radiation therapy or surgery;
- Problems with bowel control from radiation therapy; and
- Death and serious complications from surgery.
To learn more about the known harms, see the USPSTF's fact sheet (PDF File, 98 KB; PDF Help).
New results from large clinical trials have been released since the USPSTF's draft recommendation was posted for public comment in October. The Task Force examined these results, which largely supported previous findings from the same studies, and included them for consideration with this recommendation.
For unknown reasons, the death rate from prostate cancer had been climbing for two decades until about 1992, and then began to fall. PSA screening did not become a widespread clinical practice until the mid-1990s.
Because prostate cancer is such a slow-growing disease, large clinical trials have shown us that any reduction in deaths due to screening will not show up until about 7 to 10 years after screening begins. As such, the reversal in the upward trend for death rates from prostate cancer is unlikely to be from screening. A more likely explanation is the improvement in health care in general and in the treatment of prostate cancer specifically. Other cancers for which screening is not commonly performed also showed declines in death rates over the same period.
You can learn more about prostate cancer screening from these Federal Web sites:
- Prostate Cancer Screening: Questions for the Doctor (healthfinder.gov)
- Prostate Cancer Screening PDQ® (National Cancer Institute)
- Prostate Cancer (Centers for Disease Control and Prevention)
The Task Force posted a draft recommendation statement on prostate cancer that recommended against screening in October. This recommendation was open for public comment. Since October, newly released research further supported the Task Force's conclusions.
The final recommendation is similar to the draft in its final conclusions: The Task Force determined that the small benefit of a potential reduction of 1 death per 1,000 men does not outweigh the significant harms from treating prostate cancer detected by PSA screening.
Additionally, in response to the public comments received on the draft recommendation, the Task Force addressed these points in the final recommendation statement:
- A “D recommendation” does not mean clinicians and patients cannot discuss prostate cancer screening. The Task Force emphasized that clinicians and patients should discuss the possible benefits and harms, as well as individual patient preferences, before deciding to start or continue screening.
- It clarified how the recommendation applies to African American men.
- It added a table to summarize the benefits and harms of screening.
The Task Force reviewed all submitted comments on the draft recommendation statement.
The USPSTF is committed to being as transparent as possible with the public. Comments on the prostate screening recommendation have not been made public due to confidentiality concerns and other considerations, but the Task Force has a goal to make comments available to the public for future recommendations.
The Task Force is made up of 16 volunteer members who are experts in prevention and evidence based medicine. Almost all currently care for primary care patients as family physicians, general internal medicine physicians, nurses, obstetrician-gynecologists, occupational medicine physicians, and pediatricians.
The Task Force does not have any members who are urologists. However, several are respected cancer researchers. In this case, the Task Force evaluated evidence on whether primary-care practitioners should recommend PSA screening—a decision the Task Force members are expertly qualified to make. Expert urologists provided peer review of the systematic evidence review for the Task Force.
The Task Force values the input of stakeholder organizations and the public—that's why every draft recommendation statement is available on the USPSTF Web site for public comment.
The USPSTF, as an independent panel, did not collaborate with any other organizations to make this recommendation; this specific recommendation was based solely on a systematic review of available evidence that found the potential benefits of PSA-based screening for prostate cancer do not outweigh the harms. The USPSTF, however, is aware of the recommendations of other groups and includes a section in the Task Force's final recommendation statement on the guidance from other organizations. You can learn more about recommendations from other organizations such as the American Cancer Society and the American College of Preventive Medicine by visiting their Web sites.
There are seven steps in the USPSTF's process, including:
- Develop Research Plan: Task Force members work with researchers from an Evidence-based Practice Center (EPC) to create a draft Research Plan that guides the recommendation process.
- Public Comment Opportunity: The draft Research Plan is posted on the USPSTF Web site for public comment. The Task Force and EPC review all comments, address them as appropriate, and create a final Research Plan.
- Develop Evidence Report: Using the final Research Plan, the research team at the EPC independently gathers and reviews the available published evidence and creates an Evidence Report. The Evidence Report is critiqued by external national subject matter experts.
- Develop Recommendation: Task Force members discuss the Evidence Report and deliberate on the effectiveness of the service. Based on the discussion, Task Force members create a draft Recommendation.
- Public Comment Opportunity: The draft Recommendation is posted on the USPSTF Web site for public comment. The Evidence Report is finalized and published.
- Finalize Recommendation: The Task Force reviews all comments, addresses them as appropriate, and creates a final Recommendation. Members vote to ratify the final Recommendation.
- Publish & Disseminate Final Recommendation: The final Recommendation and supporting Evidence Report are posted on the Task Force Web site. Final Recommendations are also made available through electronic tools, peer-reviewed journals, and consumer guides.
To learn more about the Task Force's process, you can access the “USPSTF 101” presentation at https://www.uspreventiveservicestaskforce.org/uspstf/understanding-how-uspstf-works-uspstf-101.
The USPSTF has 16 volunteer members who are experts in prevention and evidence-based medicine. They include family physicians, internal medicine physicians, nurses, obstetrics/gynecologists, and pediatricians. They are practicing doctors and nurses, deans, medical directors, chief health officers, professors, and researchers. They are led by a chair and two vice chairs.
For biographies of the current Task Force members, visit: https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/current-members.
If you have any more questions or would like to send comments about the prostate cancer recommendation, please submit them via this form: https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/contact-us-form.