Should We Trust Screening Age Recommendations in Cancer?

When to screen and how to screen remain controversial issues in prostate cancer.

Research and historic cancer screening guidance are incompatible—or so says recent evidence. The American Cancer Society released guidance about a month back that advices women to wait an extra 5 years on a screening mammogram if they have an average risk of developing breast cancer. Now, new evidence presented at the European Association of Urology defies the recommended early screening for prostate cancer in men. “We believe that [our data] makes it clearer that most of the benefits of screening only appear after the age of 55,” according to study author Leonard Bokhorst, MD, from Erasmus University in the Netherlands.

An exhaustive retrospective study, presented at the European Multidisciplinary Meeting on Urological Cancers in Barcelona, followed more than 6800 men till the age of 75 years after they were screened for prostate cancer between 55 and 59 years of age, using Prostate Specific Antigen (PSA). Initial screening showed that 189 in the entire cohort of 6822 had prostate cancer, 40 of whom died by the end of the study period. So, about 0.6% of men could have benefitted from early screening, while the remaining 99.4% of men could have been overdiagnosed, overtreated, and would have to endure unnecessary side effects of treatment that include incontinence and impotence. This takes us back to the benefit versus harm discussion.

Bokhorst explained that population data in the Netherlands suggested 205 deaths in the cohort being studied, so “at most 10% to 20% of all expected prostate cancer deaths may benefit from earlier screening. The remaining 80% to 90% do not benefit from earlier screening as they either already benefited from screening starting at age 55 (as conducted in the study) or will not benefit at all.”

In the United States, the US Preventive Services Task Force (USPSTF) has a grade D for screening men with PSA for prostate cancer, citing potential harms of the test over benefits. False-positive results with the PSA screen, according to the USPSTF, can lead to follow-up tests that can cause unwarranted side effects such as fever, infection, bleeding, urinary problems, and pain. Further, treatment following the PSA test can result in impotence, urinary incontinence, problems with bowel control (following radiation), among others. The task force, while in the process of updating its screening guidelines for men on prostate cancer, recommends considering the person’s family history and lifestyle and consulting with a healthcare professional on expected risks prior to deciding on screening and treatment.

The American Cancer Society adds that while men should initiate this conversation with their care provider at age 50 years, a family history of prostate cancer (especially is a father or brother had the disease before age 65 years) should prompt an earlier conversation—at age 45 years.