“Smarter” Screening May Be the Answer

In their respective editorials, both Doctors Penson and Hu advocated for shared decision-making and more personalized approaches to screening. But while Dr Penson refused to support population-wide annual PSA screening, Dr Hu endorsed baseline screening, and recommended a number of additional tests. 


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“Baseline testing to establish a man’s risk for lethal prostate cancer then dictates the intensity of follow-up testing,” Dr Hu told Cancer Therapy Advisor. “We are moving away from annual PSA testing for everyone, and this risk-stratified paradigm affords a way to determine how intensely future testing should be used. Moreover, there are more biomarkers being used to help assess a man’s risk of having clinically significant prostate cancer, such as the prostate cancer antigen 3 (PCA3) test, 4K test, and prostate health index (PHI).

“There are also advances in MRI imaging that are helping the accuracy of prostate biopsy and reduction of the false negative rate,” he said. “Finally, there is greater recognition that Gleason 3+3=6 or ISUP grade 1 prostate cancer may be followed with active surveillance.

“It is clear that PSA screening has a benefit from the European study, but that the benefit isn’t as large as we would hope,” said Dr Penson. “This is likely because annual (or perhaps even semi-annual) screening results in significant over-diagnosis. Conversely, if we don’t screen at all, we lose any benefit and are likely see an increase in prostate cancer mortality because of it. To this end, the all-or-none approach forces us to choose between 2 bad choices.

“If we learn to screen more effectively, however, we can minimize over-diagnosis and maximize the benefits of screening. Different approaches tailored to a man’s risk of clinically meaningful disease will be more complicated, but the benefit could be substantial.”

“In the meantime, we should continue to allow each individual man to make an informed decision after explaining the pros and cons of treatment,” said Dr Penson. “As for developing new guidelines, I think it is highly unlikely that we will see any more large randomized clinical trials to address this issue, so we will need to use simulation modeling to figure out the best screening strategies.”

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“Blindly recommending annual screening without patient input and consent is just as wrong as not offering screening at all. We have to put the patient first,” he said.

References

  1. U.S. Preventive Services Task Force. 2012. Final recommendation statement: prostate cancer, screening. Ann Intern Med. 157(2): I-44.
  2. Schroder FH, Hugosson J, Roobol MJ, et al. Screening and prostate cancer mortality: results of the European Randomised Study of Screening for Prostate Cancer (ERSPC) at 13 years of follow-up. Lancet. 2014;384(9959):2027-35.
  3. Shoag JE, Mittal S, Hu JC. Reevaluating PSA testing rates in the PLCO trial. N Engl J Med. 2016;374(18):1795-6.
  4. Shoag JE, Schlegel PN, Hu JC. 2016. Prostate-Specific Antigen screening: time to change the dominant forces on the pendulum. J Clin Oncol. 2016 Jul 18. doi: 10.1200/JCO.2016.67.8938 [Epub ahead of print]
  5. Penson DF, Resnick MJ. 2016. Let’s not throw the baby out with the bathwater in prostate cancer screening.  J Clin Oncol. 2016 Jul 18. doi: 10.1200/JCO.2016.68.7194 [Epub ahead of print]