1. 2017 USPSTF Draft Recommendations for Prostate Cancer Screening
Michael R. Zaragoza, MD

2. USPSTF and Prostate Cancer
2002: Inadequate evidence for or against screening (Grade I) 2008: Advised against screening men > 75 yo 2012: Advised against screening all men (grade D recommendation) 2017: Advised avg risk men to discuss screening with their physician (Grade C)

3. 2017 Draft Recommendations
Clinician inform men ages about benefits/harms of PSA-based screening
Decision to be screened for prostate CA should be individual one
Individualized decision-making w clinician to understand potential risk and benefits and incorporate patient’s own values and preferences
Recommend against PSA screening for men 70 years and older

4. 2017 USPSTF Draft Benefits of Treatment (3 trials)
ProtecT: men, 50-69yo RRP and XRT compared to AS: Significant reduction of progression to mets
PIVOT: RRP vs observation Decreased mortality with surgery if PSA>10.
Scandanavian Prostate Cancer Group-4: RRP vs. WW Decreased prostate cancer-specific mortality

5. 2017 USPSTF Draft Harms of Screening Harms of Treatment
False Positives (15%)
Complications of prostate biopsy (1% hospitalization)
Harms of Treatment
Impotence (>50%)
Urinary Incontinence (20% long term)
Bowel symptoms (15%)

6. 2017 Draft Recommendations
Clinician inform men ages about benefits/harms of PSA-based screening
Decision to be screened for prostate CA should be individual one
Individualized decision-making w clinician to understand potential risk and benefits and incorporate patient’s own values and preferences
Recommend against PSA screening for men 70 years and older

7. 2017 USPSTF Draft What is Different? Grade “D” -> “C” And Why?
1. Acknowledge a net benefit in screening men 55-69, which should be balanced with potential harms
2. Individualized decision reflecting each man’s values and preferences regarding benefits and harms
And Why?
-Updated evidence from largest trial at 13 yrs: PSA screening continues to shows a reduction in prostate cancer mortality
-Harms may be mitigated by newer approach of Active Surveillance

8. 2017 USPSTF Draft What is Different and Why? Evidence Based:
Updated ERSPC and PLCO trials
1. ERSPC: Screened men 30% less like to die from CAP & 35% less likely to get metastatic disease
FU at 13yrs : 1-2 men/1000 screened to prevent death
FU at 12 yrs : 3.1/1000 screened to prevent metastasis
2. PLCO: Recognized flaws in initial trial which concluded no difference in mortality for those screened

9. Active Surveillance 2005-2009: 10% 2010-2013: 40% Active Surveillance
Trends in treatment of lower risk prostate cancer
Active Surveillance
: 10%
: 40%
Cooperberg et al, JAMA 2015

10. Effect of 2012 Recommendations
Substantial decline in PSA screening
Decreased incidence of prostate cancer
Increased proportion of high grade disease
4. Increase in metastatic disease at diagnosis

11. 2012 USPSTF Effects Decreased PSA screening rates
NHIS Data (Jemal et al, JAMA 2015):
: % -> 40.6% (+10%)
: % -> 30.8% (-18%)
Sammon, et al ( JAMA 2015):
: Overall 36% ->31%
Largest declines: yo (-5%) yo (-10%)

12. 2012 USPSTF Effects
PC Incidence rates by risk group (Barocas, et al)
Low-risk: -37%
Intermediate-Risk: %
High-Risk: -23%
Prostate Needle Biopsies, (Banerji, et al)
-More likely high risk disease (33% higher RR)
-Less likely intermediate risk disease

13. 2012 USPSTF Effects Cancer Grade at Diagnosis
Gleason’s % % (Gaylis)
Gleason’s % % (Olsson)
Gaylis et al, JCO Olsson et al, J Urol 2017

14. 2012 USPSTF Effects Incidence of Metastatic Disease
Gaylis, et al % % %
Hu, et al >75yo: % % <75yo: % %

15. 2017 Draft Recommendations
Clinician inform men ages about benefits/harms of PSA-based screening
Decision to be screened for prostate CA should be individual one
Individualized decision-making w clinician to understand potential risk and benefits and incorporate patient’s own values and preferences
Recommend against PSA screening for men 70 years and older

16. Shortcomings of 2017 Draft No recommendations for:
High Risk groups- African-American, Family Hx
Screening Intervals
Average Risk Men, ages 40-54
Healthy men > 70 yo