AAFP Updates Its PSA Screening Recommendation

FP Expert Breaks Down How It Differs From USPSTF Guidance

July 20, 2018 08:49 am Chris Crawford
[physician discussing prostate cancer with patient]

The recommendation is based on the AAFP Commission on Health of the Public and Science's examination of multiple evidence reviews the U.S. Preventive Services Task Force (USPSTF) used to formulate its final recommendation statement(www.uspreventiveservicestaskforce.org) on PSA screening for prostate cancer, which was released May 8.

In addition to a traditional systematic evidence review,(www.uspreventiveservicestaskforce.org) the USPSTF also examined a contextual review on overdiagnosis in prostate cancer screening decision models(www.uspreventiveservicestaskforce.org) and a contextual overview of prostate cancer screening decision models.(www.uspreventiveservicestaskforce.org)  

Margot Savoy, M.D., M.P.H., chair of the Commission on Health of the Public and Science, told AAFP News that the AAFP and USPSTF recommendations on the topic share similarities.

Story Highlights
  • The AAFP has issued an updated clinical preventive service recommendation on prostate-specific antigen (PSA)-based screening for prostate cancer.
  • The recommendation is based on the AAFP Commission on Health of the Public and Science's examination of multiple evidence reviews the U.S. Preventive Services Task Force (USPSTF) used to formulate its final recommendation statement on PSA screening for prostate cancer, which was released May 8.
  • The AAFP and USPSTF recommendations on the topic share similarities, but whereas the UPSTF statement is rather ambiguous about whether it recommends screening for men ages 55-69, the AAFP clearly states that it does not recommend routine PSA-based prostate cancer screening.

Both groups agree that men ages 55-69 should engage in shared decision-making with their physician to make well-informed decisions about their health, including preventive services such as prostate cancer screening -- a "C" recommendation.  

There also was agreement that men age 70 or older should not be screened for prostate cancer -- a "D" recommendation.

"The key difference is that while the UPSTF recommendation for men ages 55-69 is ambiguous about whether it actually recommends screening, we want family physicians to clearly understand that based on the currently available evidence, we do not recommend routine PSA-based prostate cancer screening," Savoy said.

Benefits/Harms of Screening

The AAFP's recommendation said that based on benefits observed in one major trial on screening (the European Randomized Study of Screening for Prostate Cancer, or ERSPC) and on treatment harms derived from pooled absolute rates in the treatment groups of three clinical trials that examined treatment, it's estimated that after 13 years, of 1,000 men ages 55-69 who were screened for prostate cancer, 100 will be diagnosed with the disease.

"As the result of early treatment, 1.3 men will avoid dying of prostate cancer, while five men will die of prostate cancer despite treatment," the recommendation said. "It is also estimated that screening will result in three fewer cases of metastatic prostate cancer."

Additionally, the Academy said that although the mortality benefit of prostate cancer screening results from early treatment, it is the treatment of prostate cancer that causes the most serious harms.

"These potential harms are particularly concerning given the high rate of overdiagnosis associated with prostate cancer screening," the recommendation noted. "Overdiagnosis involves the diagnosis of asymptomatic cancer that never would have resulted in symptoms or death."

It's estimated that overdiagnosis from prostate cancer screening could mean that up to half of men exposed to the harms of treatment would never have been affected by their cancer.

Further Discussion

Savoy said PSA testing for prostate cancer doesn't belong on the family physician's list of routine preventive service recommendations for patients in this age group.

"If, while discussing his personal history and risk factors, the patient requests PSA testing, we recommend the family physician discuss both the risks and benefits with the patient," she said. "This conversation can get confusing at times, so we recommend using evidence-based tools that can display the information in an easy-to-understand way."

One such tool, said Savoy, is a USPSTF infographic(screeningforprostatecancer.org) that provides a succinct by-the-numbers roundup of potential benefits and harms associated with screening.

"Ultimately, the patient will make the decision about whether he wants to have the PSA test done or not," she said. "However, based on the current research data we have available, we don't recommend any patient be screened for prostate cancer with PSA."

Men at High Risk for Prostate Cancer

There are some groups of patients, Savoy noted -- specifically, African-American men and men with a family history of prostate cancer -- who have higher rates of prostate cancer and related mortality from the disease.

"African-American men and men with a family history of prostate cancer should be informed of their increased risk of developing prostate cancer in addition to the benefits and harms of screening so that they may make an informed choice," Savoy said.

The AAFP strongly encourages researchers to include high-risk groups, such as African-Americans, in future studies about prostate cancer screening, she added.

"It's critical for us to start being deliberate and insisting that we include diverse patient populations in our research studies so we can know if a screening, intervention or medication works across all people," she said. "These research blind spots contribute to the ongoing health disparities we see in the U.S. and limit the care we provide our patients."

This is why, Savoy went on to say, the AAFP is invested in projects such as its The EveryONE Project and NIH's All of Us research initiative.(allofus.nih.gov)  

"Unless everyone is included in the studies, we will continue to have these gaps in knowledge," she cautioned, "and that is unacceptable."

AAFP Updates Recommendation Process

The AAFP has a long history of providing evidence-based clinical recommendations to its members and relies on the Commission on Health of the Public and Science to review the evidence and make recommendations to the Academy's Board of Directors about clinical preventive services, as well as treatment and management guidelines.

"We regularly lead our own guideline-writing panels and participate in other organizations' panels or review process when the content is likely to be of benefit to our membership," Savoy said. "Our evidence-based approach has been a source of pride and recognition from external professional organizations."

The AAFP has a longstanding partnership with the USPSTF and the Agency for Healthcare Research and Quality -- which provides administrative, research, technical and communication support to the task force -- and participates in all the steps involved in developing the group's preventive services recommendations, which include

  • nominating qualified family physicians to serve on the task force,
  • nominating topics for evidence reviews and potential recommendations,
  • commenting on draft recommendations and evidence reports, and
  • reviewing final recommendations.

The Commission on Health of the Public and Science, specifically, reviews all draft evidence reports and recommendations from the USPSTF and provides feedback the task force considers when finalizing its recommendation statement. After the USPSTF releases its final recommendation, it also is reviewed, and the AAFP determines whether it will support the task force's recommendation or develop its own, as it did for prostate cancer screening.

When the AAFP develops a differing recommendation, additional information on implementation and clinical considerations will be highlighted to provide guidance to members.

"We hope our membership is noticing that we are being much more deliberate about communicating with our practicing family physicians when prominent or potentially practice-changing guidelines are released," Savoy said.

Occasionally, said Savoy, a new guideline may not adequately address situations family physicians face in practice, or the evidence supporting the new guideline may fall below the high level of rigor the Academy's membership has come to expect.

"In those cases, we decided providing accessible, evidence-based information will allow our members to be in the strongest position to make their own clinical judgments while providing the best care for their patients," she concluded.

Members are invited to review the AAFP's collection of clinical practice guidelines -- both its own and those from other groups that the Academy has endorsed -- along with its policy on endorsing external clinical guidelines, as well as that on external guidelines it does not endorse.  

Related AAFP News Coverage
USPSTF Final Recommendation
Personalize Decisions on PSA Screening for Men Ages 55-69

(5/11/2018)

USPSTF Draft Recommendation
Individualize Decisions on PSA Screening for Men Ages 55-69

(4/11/2017)

More From AAFP
American Family Physician: Prostate Cancer Screening

American Family Physician: AFP by Topic: Prostate Disorders