Position on USPSTF Guidelines for Prostate Screening
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Overview
The United States Preventive Services Task Force (USPSTF) recently issued a draft of recommended changes for prostate cancer screening in men. The current draft guidelines recommend against PSA screening for men of any age. Although the guidelines were not written specifically for men with BRCA mutations, FORCE is concerned that the proposed screening guideline changes as written may have serious negative health implications, lead to confusion, and make it more difficult for high-risk men to get insurance reimbursement for PSA screening.
Background on USPSTF new draft guidelines
According to the USPSTF, the primary goal of prostate cancer screening is to reduce deaths due to prostate cancer. Research shows that screening using PSA increases detection of prostate cancer. However, PSA screening has risks and limitations including:
- many of the cancers found are not symptomatic and will not progress to a point of affecting life-span or quality-of-life
- PSA tests yield many false-positive results leading to unnecessary biopsies
- treatment of prostate cancer can lead to serious side effects in about 7% of patients and less serious side effects in as many as 40% of patients
Given the above, the USPSTF analyzed research studies that looked at prostate cancer screening and outcomes to determine if the research showed a net benefit from screening. The Task Force examined research studies that included men of average risk and men who were considered high risk due to a family history of prostate cancer, but did not evaluate any studies looking at men with or likely to have a BRCA mutation.
Background on prostate cancer in BRCA 2 mutation carriers
Men with BRCA 2 mutations face
- a lifetime risk for prostate cancer that is much higher than men in the general population and may be as high as 33%,
- prostate cancer risk at a younger age than the general population, and
- risk for more aggressive prostate cancers.
Edwards et. al. recently published data which showed a poorer prognosis and overall survival for BRCA2 mutation carriers versus non-carriers diagnosed with prostate cancer. Based on this and previous work, BRCA2 mutation status is now recognized as an independent prognostic factor and marker of poorer overall survival. The IMPACT Trial is a large international study examining PSA in men with and without BRCA mutations. The study will be completed in 2020 and will determine if PSA screening improves detection and outcomes in mutation carriers. Early analysis from IMPACT suggests a benefit of PSA screening in men with BRCA mutations.
Conclusion
The benefit/risk ratio for prostate cancer screening is likely different for men with BRCA mutations compared to men in the general population. Before a sweeping recommendation is made against all PSA screening, it is important to take into account and delineate men for whom these guideline changes might not be appropriate.
FORCE position statement on USPSTF prostate cancer screening guideline changes
Facing Our Risk of Cancer Empowered (FORCE) is the only national nonprofit organization devoted to people and families affected by hereditary breast and ovarian cancer. Our mission includes education and advocacy to help people to make informed decisions about their health, including decisions about cancer screening. We are concerned that these policy changes in prostate cancer screening guidelines might affect health care coverage for screening of men with BRCA mutations.
The USPSTF draft recommendations apply to men of average risk and men who are high risk because of race or a family history of prostate cancer, but the guidelines do not consider men with a BRCA mutation. Given that:
- There is data that lifetime prostate cancer risk is increased in men with BRCA2 mutations
- One of the concerns about PSA screening is that it identifies less aggressive prostate cancers as well as more aggressive tumors and that treating these less aggressive cancers may have more harm than benefit. For men with BRCA 2 mutations there is solid research evidence that their prostate cancers are more aggressive than in men with sporadic cancer.
- There is early evidence from the IMPACT Trial that PSA screening may identify the more aggressive prostate cancers in BRCA2 carriers.
We ask the USPSTF to reserve judgment on the use of PSA screening in men with BRCA mutations until the definitive data are available, which is expected to be in 2020.
Call to action
FORCE appreciates and respects the USPSTF’s expertise and the value of reviewing scientific research on critical issues affecting public health, however any evaluation of risk/benefit in determining guidelines needs to take into account and clearly delineate those populations for whom the guidelines may not apply. In the meantime:
- we urge the USPSTF to add language to the guidelines to clarify that they are not meant for men with a BRCA mutation or those with a high-likelihood of carrying a mutation.
- We strongly encourage the government and health care community to ensure that all men have access to risk-assessment expertise and tools that allow them to understand their personal risks and thus make informed decisions about their care.
- We encourage men with a BRCA mutation to participate in the ongoing IMPACT study by contacting the study coordinator at your closest study site.
References
Page updated 11/30/11
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