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Published on July 16, 2018

This cancer kills more men on Cape Cod than any otherThis cancer kills more men on Cape Cod than any other

The U.S. Preventative Services Task Force released new guidelines for prostate cancer testing last month and, while they are an improvement on the 2012 recommendations, they don’t go far enough in doing what’s best for the individual, said J. Keith Bleiler, MD, a Falmouth Hospital urologist.

“I think USPSTF made the change in part because there was such a huge backlash from urologists disagreeing with the recommendation not to test,” Dr. Bleiler said.

The 2012 guidelines from the U.S. Preventative Task Force (USPSTF) recommended no prostate cancer screening unless the patient requested the test on their own, he said. The new guidelines represent a change in the view of. The group is now recommending that men ages 55-69 discuss the possible benefits and harms of prostate-specific antigen (PSA) screening with their clinician before deciding to be tested.

Definition of the Grades

The U.S. Preventative Task Force (USPSTF) designates letter grades A,B,C,D, and I for their recommendations for PSA testing, based on the benefits versus harms of testing and treatment. The following grades are the changes made to the “C” and “D” grades:

  • In 2012, the grade of “D” stated “The UPSTF recommends against this service [PSA testing]. There is moderate or high certainty that the service has no net benefit or the harms outweigh the benefits.”
  • The 2018 designation of “C” states “For men age 55 to 69 years, the decision to undergo periodic prostate-antigen specific screening for prostate cancer should be an individual one. Before deciding whether to be screened, men should have the opportunity to discuss the potential benefits and harms of screening with their clinician and to incorporate their values and preferences in the decision.”
  • The 2018 recommendations placed men who are over 70 in the “D” recommendation. “The USPSTF recommends against PSA-based screening for prostate cancer in men age 70 years and older.”

The USPSTF’s original designation that men should not be screened was based on their assessment that the harms of the screening test outweighed the benefits, said Dr. Bleiler.

“What they hang their hat on are the potential complications associated with the PSA test. I don’t think there are any complications at all, it’s just a blood test,” he said.

The USPSTF believes the test leads to false positives, and potential harm because it leads a patient down a path to unnecessary treatment.

“They’re making a quantum leap between a blood test and a man who may suffer life-long incontinence and erectile dysfunction [after treatment], which I think is wrong,” said Dr. Bleiler. “They make the assumption that any man diagnosed with prostate cancer is going to be funneled into a treatment protocol that is going to give him these life-long side effects. It’s not an absolute that you’ll have those side effects, we have patients in our practice who are continent and have normal erectile function even after major surgery.”

Dr. Bleiler is concerned the new guidelines misinforms patients because they won’t think they need to get checked or screened. Prostate cancer is the number one cancer cause of death in men in Barnstable County, he said. While the odds of dying from prostate cancer are low, all the urologists have patients in their practices dying from prostate cancer, he added.

“I think every man over the age of 40 should have a baseline PSA test, especially between 45 and 50, if there was a family history for prostate cancer,” said Dr. Bleiler.

New Types of Testing

While PSA is the only screening test to identify men who may be at risk for prostate cancer, according to Dr. Bleiler, there are other tests that can help determine whether a patient can be monitored or needs treatment. New molecular techniques can identify men with low-volume, low-grade prostate cancer who are good candidates for active surveillance versus treatment. Some cancers that appear to be a higher grade may be less aggressive and some cancers that appear to be low grade can appear more aggressive.

Other tests include Oncotype DX, Prolaris and Decipher, which look at gene expression to identify men who may be at a higher risk than others. There is also the Myriad genetics myRisk test that can look to see if asymptomatic men without prostate cancer may need to be screened more closely when he has a family history.

Two other tests, the “Select MDx” and a relatively new blood test called “Prostate Health Index” assess the risk of significant prostate cancer, according to Dr. Bleiler.

Dr. Beiler remains concerned about the newest guidelines, especially when they don’t address the high risk of prostate cancer in African-American men and don’t recommend PSA testing for men age 70 and over. But he is hopeful that it will force development of new and innovative screening modalities.

“I think we should always be pushing forward in trying to identify new and better ways of doing this,” he said.