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Six years after recommending against PSA testing for everyone, the same body changed its mind for men aged 55 to 69 and said the decision should be theirs. The statement puts the numbers on both sides: about 1.3 deaths prevented per 1,000 men screened, and one in five who have surgery left with long-term incontinence.
The United States Preventive Services Task Force updated the 2012 grade D statement after reviewing the trials, commissioning a review of decision-analysis models and commissioning a separate review of the overdiagnosis rate, including in subgroups at higher risk: older men, African American men and men with a family history.
The 2018 statement is unusually useful to read as a patient because it states the benefit and the harm in the same units. Screening men aged 55 to 69 may prevent about 1.3 prostate cancer deaths and about 3 cases of metastatic disease per 1,000 men screened over about 13 years. Against that: about 1 in 5 men who have radical prostatectomy develop long-term urinary incontinence and 2 in 3 experience long-term erectile dysfunction. The task force concluded the net benefit is small for some men and that clinicians should not screen men who do not express a preference for it.
The current shape of the screening question in the United States, and the best short statement of the trade-off in numbers a man can weigh. The three-to-one ratio between metastatic cases prevented and deaths prevented is also the argument for using metastatic presentation, not mortality, to judge a screening programme sooner.
Long-term data support active surveillance as a safe choice for low and much intermediate-risk disease, while the lower metastasis rate with treatment informs the discussion for men with longer life expectancy.
The disparity in prostate cancer death among Black men in the United States is, stage for stage and treatment for treatment, largely a disparity in getting standard care rather than in tumour biology. The disparity that survives equal access is in dying of everything else, which is the part a cancer service is least organised to fix and most able to measure.
The clearest case in cancer screening of a national body acting on the harms rather than the headline. Whether it was right is still argued: testing and localised-stage diagnosis fell, and the long-term effect on metastatic presentation and mortality is the subject of the studies that followed.
Shares Overdiagnosis and overtreatment of prostate cancer, Number needed to screen (and number needed to diagnose), Overtreatment, Judge a prostate screening programme on metastatic presentation, not on incidence or mortality and the tag prostate-evidence.
Shares ProtecT: fifteen-year outcomes after monitoring, surgery or radiotherapy for prostate cancer, Other-cause mortality, Overtreatment, Overdiagnosis and the tag prostate-evidence.
Shares USPSTF 2012: screening for prostate cancer, recommendation statement (grade D), Number needed to screen (and number needed to diagnose), Judge a prostate screening programme on metastatic presentation, not on incidence or mortality, Overdiagnosis and the tag prostate-evidence.
Shares USPSTF 2012: screening for prostate cancer, recommendation statement (grade D), Number needed to screen (and number needed to diagnose), PSA (prostate-specific antigen), Localised prostate cancer, intermediate risk and the tag prostate-evidence.
Shares Overdiagnosis and overtreatment of prostate cancer, Overtreatment, Overdiagnosis, PSA (prostate-specific antigen) and the tag prostate-evidence.
Shares ProtecT: fifteen-year outcomes after monitoring, surgery or radiotherapy for prostate cancer, Other-cause mortality, Overtreatment, Overdiagnosis and the tag prostate-evidence.
Shares Number needed to screen (and number needed to diagnose), PSA (prostate-specific antigen), Localised prostate cancer, intermediate risk, Localised prostate cancer, very low and low risk and the tag prostate-evidence.
Shares Association of Black race with prostate cancer-specific and other-cause mortality, Other-cause mortality, Report death from other causes as an outcome of the prostate cancer service, split by deprivation and ethnicity, Screening and the tag prostate-evidence.