In May 2012, the U.S. Preventive Services Task Force issued a Grade D recommendation against prostate-specific antigen (PSA)-based screening for prostate cancer diagnosis. Since then, epidemiologists have raised concerns that an unintended consequence of the recommendation could be a problematic increase in high-risk disease and its subsequent impact on the risk of prostate cancer progression and mortality.
Dr Thomas Ahlering, a urologic oncologist from the University of California, Irvine, California, USA, presented the first study that utilises high-risk oncologic metrics to assess the impact that the Grade D recommendation has on high-risk disease presentation at the time of radical prostatectomy. The case series analysis utilised data from 19,602 patients undergoing robot-assisted radical prostatectomy from nine high-volume institutions throughout the USA. The potential effect of reduced PSA screening was assessed by comparing the absolute number of patients (at each institution and collectively) with seminal vesicle invasion, lymph node metastasis, and Gleason score 9 and 10 cancers 4 years pre versus post recommendation.
Compared to the 4-year average, pre (October 2008–September 2012) versus post recommendation (October 2012–September 2016), there was a 22.6% reduction in surgical volume, and, as anticipated, an increase in median PSA (from 5.1 to 5.8 ng/mL), and an increase in mean age (from 60.8 to 62.0 years). However, there was a near-doubling in the absolute number of Gleason score 9 and 10 cancers, and a tripling of nodal metastases. The 1-year biochemical recurrence post-radical prostatectomy rose from 6.2% to 17.5%.
One of the strengths of this study was the use of propensity score matching for age and PSA across the screening eras. Not only do the authors report an increase in more aggressive disease in the post recommendation era but also a stepwise increase in high-risk disease each year subsequent to the recommendation. In other words, for any given age and PSA, propensity matching suggests that there may be a trend for more aggressive disease post recommendation. While changes in referral pattern and/or the use of radiation therapy may contribute to some of this impact, these limitations need to be considered within the context of these findings. The current study joins the growing body of literature in raising concerns of a shift towards high-risk disease, associated increases in biochemical recurrence, and secondary interventions (and their side effects) following the U.S. Preventive Services Task Force recommendation.