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Dear Editors – On behalf of the membership of the NCCN guidelines panel on the Early Detection of Prostate Cancer, we disagree with the assertions of Drs. Jatoi and Sah that the NCCN guidelines drive the overuse of health care services and conflict with evidence-based recommendations of other independent organizations.
Without specific evidence, Drs. Jatoi and Sah argue that, through its advocacy of population-based prostate-specific antigen (PSA) screening for early detection of prostate cancer in selected, well – informed men, the NCCN guidelines serve the financial interests of providers rather than patients. They extol the recommendations of “independent” multidisciplinary panels, including the United States Preventive Services Task Force (USPSTF)( USPST, Grossman DC, Curry SJ, et al. Screening for Prostate Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319(18):1901-1913.) and assert that, unlike these panels, the NCCN promotes recommendations biased in favor of specialists.
However, they fail to note that the USPSTF currently recommends consideration of PSA screening as part of shared decision making for men aged 55 to 69 years. This inconsistency in their argument is troubling. Moreover, they cite two outdated recommendations against PSA screening—the Canadian Task Force on Preventive Care of 2014 and the European Society of Medical Oncology Consensus Panel of 2012 (Annals of Oncology 24: 1141–1162, 2013)—that do not incorporate the latest Level I evidence on this topic.
In contrast, the NCCN guideline is updated at least annually and includes detailed information on who and how to screen. The current guideline (v1.2019, published January 31, 2019) addresses the benefits and harms of screening and is clear on several relevant issues: (1) in alignment with the USPSTF recommendations, the decision to undertake screening is a "shared" one between patient and provider; (2) patients in poor health and of limited life expectancy should not be screened; (3) in those with an elevated PSA, alternatives to prostate biopsy exist which significantly reduce the risk of unnecessary biopsies; (4) active surveillance is the appropriate form of treatment for many men diagnosed with prostate cancer; and (5) optimal guidelines for those who are African American and/or those with a family history of disease remain undefined, but these groups should be considered for early assessment.
Furthermore, the NCCN guideline notes that the rationale for considering screening at earlier age is based on data demonstrating: (1) a baseline serum PSA at age 45 is a strong predictor of the future risk of lethal prostate cancer; (2) there is less PSA confounding by BPH at earlier ages; (3) a small but significant number of men already have high-risk or advanced prostate cancer by their early 50s; and (4) screening can be tailored to baseline risk (i.e. lower PSA at younger ages allows for less frequent PSA testing). The guideline also points out that, based on serum PSA levels in men in their 60s, many may safely stop screening at age 70 years.
Guidelines for screening for any cancer should not simply be attributed to specialty bias, but based on the strength, currency and depth of the evidence on which they are based.
Sincerely,
Peter R. Carroll, MD, MPH
Professor and Chair
Ken and Donna Derr – Chevron Distinguished Professor
Taube Family Distinguished Professor
Department of Urology
University of California, San Francisco
J. Kellogg Parsons, MD, MHS, FACS
Professor and Endowed Chair for Clinical Research
Department of Urology
Director of Genitourinary Clinical and Translational Research
Moores UCSD Comprehensive Cancer Center
UC San Diego Health