How Can Guidelines Give Clearer Guidance on Prostate Cancer Screening?

Sigrid V. Carlsson; William K. Oh

doi:10.1001/jamaoncol.2024.3909

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September 26, 2024

How Can Guidelines Give Clearer Guidance on Prostate Cancer Screening?

Sigrid V.聽Carlsson,聽MD, PhD, MPH^1,2,3; William K.聽Oh,聽MD⁴

Author Affiliations Article Information

¹Department of Surgery (Urology Service) and Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
²Department of Urology, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
³Department of Translational Medicine, Division of Urological Cancers, Medical Faculty, Lund University, Lund, Sweden
⁴Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, New York

JAMA Oncol. 2024;10(11):1497-1498. doi:10.1001/jamaoncol.2024.3909

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Guidelines are clear on when women should get mammograms to screen for breast cancer, but men face conflicting and confusing advice on prostate cancer screening. This is concerning, given that prostate cancer is the most common cancer and the second most common cause of cancer death among men in the US.¹ Randomized clinical trials (RCTs) have shown that regular prostate-specific antigen (PSA) screening can reduce prostate cancer mortality by 30% within 2 decades of follow-up (reanalysis of the European Randomized Study of Screening for Prostate Cancer and the Prostate Lung Colorectal and Ovarian Cancer Screening trial).² Yet, recommendations from guideline groups vary widely (Table). In our view, guideline groups must come together to agree on a framework that produces clear and unified recommendations on prostate cancer screening.

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September 27, 2024

Prostate Cancer Screening Guideline: Evidence-based or Expert Opinion?

Takeshi Takehashi, M.D, Ph.D | Kitakyushu city, public health physician (3yrs), ex-urologic surgeon (30yrs)

The viewpoint presented in this article, which suggests that prostate cancer screening should be justified based on expert opinion from urologists, lacks a solid foundation in the principles of medical and life sciences.

The USPSTF statement stands as the only evidence-based guideline for prostate cancer screening. Other guidelines cited in this article are primarily based on expert opinions derived from case reports by urology specialists. In the hierarchy of evidence, randomized controlled trials (RCTs) are positioned at the top, while case reports and expert opinions fall at the lower end.

The USPSTF comprises public health physicians who are skilled in evidence evaluation and operate without conflicts of interest. In contrast, members of organizations like EAU, AUA and NCCN are urologists. While they possess expertise in prostate cancer care, they may lack the necessary skills to critically assess the evidence and are susceptible to both direct and indirect conflicts of interest. Additionally, these guidelines, published in urology and oncology journals, have not undergone peer review by public health experts.

Currently, there is no evidence that screen-detected prostate cancer is biologically malignant. This concept originated as a hypothesis proposed by a single pathologist in the 1950s. Factors related to screening鈥攕uch as PSA threshold, TNM classification (T1c category), and Gleason scores鈥攚ere arbitrarily established by expert urologists and pathologists based on this hypothesis. Therefore, prostate cancer screening, along with subsequent imaging and treatment, constitutes an empirical or experimental medical practice. Most clinical trials on this topic, apart from the three aforementioned RCTs, consist of case series without control groups, which severely limits meaningful comparisons and statistical analysis. [1-3]

Proponents of prostate cancer screening, urologists and pathologists, bear the responsibility of providing clear evidence. If doing so proves too labor-intensive or costly, then experimental practices that pose risks without clear benefits should be discontinued.

Overall mortality remains the most reliable endpoint. If a cancer screening is shown to reduce cancer mortality but fails to lower overall mortality鈥攅specially among the elderly鈥攖his indicates overdiagnosis, making screening for that age group inadvisable. The evidence that prostate cancer screening effectively reduces cancer mortality is uncertain, and the consensus among three RCTs is that it does not diminish overall mortality, implying that early detection and treatment of prostate cancer may not be clinically significant. This issue transcends age groups, affecting all demographics. The 2012 USPSTF D recommendation is, therefore, justified; the USPSTF's error lay in succumbing to interest groups and expert opinion, thus misapplying the concept of overdiagnosis.

The statement 鈥淧SA screening is here to stay. The horse has already left the barn鈥� may seem reckless. A significant issue arises from the fact that, in some countries, prostate cancer screening and subsequent tests and treatments are funded by public health insurance. This situation presents considerable challenges for healthcare economics and medical ethics, as it contradicts the principles outlined in the Declaration of Helsinki. [4]

REFERENCE
1. Takahashi T. BJU Int. 2024 Aug 29. doi: 10.1111/bju.16525.
2. Takahashi T. Br J Gen Pract. 2024 Aug 29;74(746):397.
3. Takahashi T. Virchows Arch. 2024 Aug 20. doi: 10.1007/s00428-024-03900-x.
4. Takahashi T. JAMA Oncol. 2023 Jun 1;9(6):86

CONFLICT OF INTEREST: None Reported

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