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Why this prostate cancer screening guideline just got reversed

April 11, 2017 at 6:30 PM EDT
Five years ago, men aged 55 and over were advised not to undergo the common test for prostate cancer. Now those guidelines have changed, and men 55 to 69 are now being told that they should consider getting tested. William Brangham speaks with Dr. Kirsten Bibbins-Domingo, chair of the U.S. Preventive Services Task Force.
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JUDY WOODRUFF: Each year, 26,000 men in the United States die from prostate cancer. But there is confusion over conflicting advice about whom should get tested for the disease. There is new guidance out today from an influential task force.

Our William Brangham has that story.

WILLIAM BRANGHAM: Here’s where some of the confusion started.

Five years ago, the U.S. Preventive Services Task Force told men aged 55 and over not to undergo the common PSA test for prostate cancer, citing fears of overtreatment or false positives.

But, today, that panel reversed course, saying that men 55 to 69 should consider the test, but that men 70 and over should still skip it.

I’m joined now by the doctor who chairs that task force.

Dr. Kirsten Bibbins-Domingo is an general internist at U.C. San Francisco.

Welcome to the NewsHour.

DR. KIRSTEN BIBBINS-DOMINGO, Chair, U.S. Preventive Services Task Force: Thank you for having me.

WILLIAM BRANGHAM: So, forgive my sense of whiplash here, but help me understand, what is the task force recommending today? What’s the evidence behind your recommendation?

DR. KIRSTEN BIBBINS-DOMINGO: The task force is recommending that men between the ages of 55 and 69 have a conversation with their doctor about prostate cancer screening.

We want men to know about the benefits of screening. We want them to also be aware of the harms that might occur along the along the way during the process of screening. The key here is that men should have this discussion. They should be aware the benefits and harms and then make the right decision that’s right for them.

WILLIAM BRANGHAM: Well, what would be the harms? I can understand the benefits. They can find out whether you have cancer or not, but what are the harms involved?

DR. KIRSTEN BIBBINS-DOMINGO: The challenge with prostate cancer screening is the test that we use, the PSA test, is not that good for distinguishing the types of cancers that are going to cause problems, the aggressive cancers, distinguishing those from those that are slow-growing and may not cause a man a problem during his lifetime.

And since most men who get diagnosed end up getting treated, those men are then subjected to the harms of treatment, which are important, and include impotence and incontinence, harms that happen in most men.

We’re fortunate that the task force has new evidence. We have new evidence that led to the change in our grade. And the new evidence is both about the benefits, but also about approaches that can be used to allow some men to reduce some of these harms.

WILLIAM BRANGHAM: So, let’s just say I’m one of these men, I get the test, and the PSA test indicates that I have cancer. What’s next?

DR. KIRSTEN BIBBINS-DOMINGO: So, after the PSA test, you would have to have a prostate biopsy. That’s what would be important for us to really determine whether you have cancer.

The strategy called active surveillance was one of those new strategies that we reviewed evidence for in the update. If you have low-risk prostate cancer, this might allow you to — active surveillance might allow you to avoid or delay treatment, because we watch you over time to see if the cancer is progressing, and only treat those men whose cancer is progressing.

And so that was what allowed us to say that, for some men, the harms might be reduced.

WILLIAM BRANGHAM: So, if I understand correctly, the new evidence that has helped you change your minds was that this testing saves more lives than it hurts in these ancillary side effects?

DR. KIRSTEN BIBBINS-DOMINGO: Well, I think the most important thing to say is that there are benefits and there are harms, and what that balance looks like for any given man depends on how he values those benefits and harms.

So, some men might say, I want to reduce my chance of dying of prostate cancer no matter what. I don’t care about the risks that you’re talking about. Let’s go ahead.

There are other men who might say, the likelihood of benefiting from screening is so small. It’s only about one or two men in 1,000 screened who actually are prevented from dying. That man might say, that likelihood is too low, and I’m not willing to be — to subject myself to the potential risks associated with screening.

WILLIAM BRANGHAM: And there’s a lot of urologists — and I know the American cancer society has come out. They are very happy with your new guidelines.

There are other doctors who have said this is a complicated conversation that you’re asking people to have with their doctors, doctors don’t have a lot of time to talk their patients, and that they worry that these guidelines will be blanket everybody get a PSA test, and that then we will see all of these negative side effects.

How do you weigh that concern?

DR. KIRSTEN BIBBINS-DOMINGO: Well, it’s definitely true that these are complex discussions. These are complex decisions.

We do think that every man deserves to really understand what the science is telling them. And that’s why we really emphasize that these discussions are important ones to be had between doctors and patients to really understand, for any given man, what is the right choice for him?

We are happy that many have engaged in the conversation. And it’s rally important that we get the right input and have the discussion about our draft recommendation. But, in the end, the most important thing for a given man is that he is aware that the science is telling us about benefits and harms, and that he uses that together to make the right decision for himself.

WILLIAM BRANGHAM: So, the recommendations are, 55 to 69, strongly consider the test, talk to your doctor about it, men over 70, not necessary.

What about younger men under 55?

DR. KIRSTEN BIBBINS-DOMINGO: So, there are definite gaps in our evidence right now.

We’d like to have better research about the types of tests that we could use to screen for prostate cancer. I told you PSA test is not a great test. We’d like to have more research on high-risk men. We know that African-American men have higher risks of prostate cancer. So do men with a family history.

A lot of times, these are the types of cancer that occur in men earlier in life. We just don’t have enough evidence about how we can screen those men effectively, what’s the best age to start, how often to screen. We really need evidence for these men.

In the absence of that evidence, I would say that our recommendations definitely apply to these high-risk men. That’s important to get out there. But we also need more research.

WILLIAM BRANGHAM: All right, Dr. Kirsten Bibbins-Domingo, thank you very much.

DR. KIRSTEN BIBBINS-DOMINGO: Thank you.

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