Guideline: Experts recommend against prostate cancer screening with prostate-specific antigen test

Abstract

Guideline scope Use of prostate-specific antigen (PSA) screening for prostate cancer. Guideline development methods An international BMJ Rapid Recommendations panel, which included men at risk for prostate cancer, clinicians from relevant fields, epidemiologists, methodologists, and statisticians, developed a recommendation based on a systematic review {searches done to Apr 2018}*. The review included 5 randomized controlled trials (RCTs) (n =721718, median age 59 y reported in 2 trials). Evidence was appraised using the GRADE approach and considered patient values and preferences; the balance of benefits, harms, and burdens of screening; quality of evidence for each outcome; and treatment feasibility and acceptability. Results and recommendations The expert panel made a weak recommendation against systematic PSA screening for prostate cancer (harms outweigh the benefits for most people but not everyone; most people would likely not want this option). Screening or not screening is reasonable; shared decision making is needed for men considering screening. An online version of the recommendation and evidence summary is available at www.bmj.com/content/362/bmj.k3581 and with decision aids at app.magicapp.org/app#/guideline/2790. Conclusion Based on current best evidence, a guideline panel made a weak recommendation against prostate-specific antigen (PSA) screening for prostate cancer and recommended shared decision making for men considering screening. Prostate-specific antigen (PSA) screening vs no screening for prostate cancer Outcomes Population of men Number of trials (n) Event rates At 10 to 20 y PSA screening No screening ARR (95% CI) NNS (CI) All-cause mortality All 4 (675232) 12.8% 12.9% 0.1% (0.1 to 0.3) Not significant Prostate cancer mortality All 5 (721718) 0.3% 0.3% 0.0% {0.08 to 0.08} Not significant African descent 1 (162243) 0.6% 0.7% 0.1% (0.1 to 0.2) 1000 (500 to 1000) Advanced prostate cancer All 3 (647751) 1.1% 1.3% 0.2% (0 to 0.4) 500 (250 to ) ARI (CI) NNH (CI) Any prostate cancer All 4 (675232) 3.9% 3.2% 0.7% (0.1 to 1.5) 143 (67 to 1000) Family history of prostate cancer 1 (162243) 7.9% 5.0% 2.9% (2.6 to 3.1) 35 (33 to 39) African descent 1 (162243) 8.0% 5.1% 2.9% (2.6 to 3.2) 35 (32 to 39) Localized prostate cancer All 3 (647751) 2.6% 1.9% 0.7% (0.2 to 1.5) 143 (67 to 500) Family history of prostate cancer 1 (162243) 4.4% 2.5% 1.9% (1.7 to 2.1) 53 (48 to 59) Mean values Mean difference (CI) Quality of life All 1 (1088) 0.75 0.76 0.01 (0.01 to 0.02) Not significant ARI = absolute risk increase; ARR = absolute risk reduction; NNS = number needed to screen; other abbreviations defined in Glossary. NNS, NNH, and CIs calculated from absolute differences and CIs in articles. Findings are based on moderate-quality evidence (all-cause mortality) or low-quality evidence (all other outcomes) based on the GRADE approach. Information provided by author. At 13 y. Short-Form Six-Dimension health index (score range 0 to 1; higher score = better quality of life). Commentary The BMJ Rapid Recommendation and associated systematic review (1) of RCTs of PSA screening paint a relatively consistent picture of downstream effects. Benefits are small or nonexistent, whereas harms are well-established and clinically important. Prevention of prostate cancer deaths, the most meaningful potential benefit, is small at most (1 additional prostate cancer death prevented/1000 men/10 y), and the pooled effect is statistically consistent with no effect at all. There is also no effect on total mortality. Potential harms of diagnostic work-up with biopsy in men with positive PSA results include infection, even sepsis, as well as pain and bleeding. Treatment causes substantial rates of incontinence and erectile dysfunction. As summarized by Tikkinen and colleagues, 10 major guidelines, with 1 exception, either recommend against or do not recommend PSA screening, and most suggest shared decision making. Of course, the guidelines differ in some details, mainly the age at which screening should be discussed and whether (in the absence of convincing evidence) men should be screened differently according to race and family history. This inconsistency is expected when guideline panels from many parts of the world and many specialties apply their own value judgments to the same evidence. The prompt for the BMJ Rapid Recommendation guideline was the publication of a British trial (2) that was so large (contributing 419582 of the 721718 men in published trials) that it might have changed the pooled estimates of screening effects. It did not affect the estimates to a meaningful extent. This guideline is unique in recommending that PSA screening need not be considered at all unless a patient or doctor decides to do so. I think most will choose to discuss. Currently, the main challenge is providing realistic advice on how to share decision making, not a lack of convincing evidence on benefits and harms. A thorny issue is how to communicate the right impression of risk, which has no gold standard and is sensitive to framing. Also, expert groups recommend an extensive agenda for shared decision making (3). This is a daunting task in busy practice settings, even with decision aidsso much ground is supposed to be covered, and many other health issues deserve attention.