How the Risk of Treatment Complications Impacts Prostate Cancer Screening (PSA) Guidelines

In early April, the U.S. Preventative Services Task Force (USPSTF) issued a new draft recommendation statement on PSA-based screening for prostate cancer, raising the grade from a D to a C. Rather than discouraging screening outright, the USPSTF appears ready to embrace more individualized decision-making about the best options for care. The independent group of experts continues to highlight the risk for treatment complications including incontinence and impotence as a driving factor in their conclusion that screening has a small net benefit overall. Advancing clinical research programs and developing new medical technology to help mitigate the risk for treatment complications might have a dramatic impact on screening recommendations for future generations.

The three most common treatment options for localized prostate cancer are surgery, radiation therapy, and active surveillance. Along with an extremely high survival rate if detected early enough, only a small percentage of men diagnosed have an aggressive form of the disease, contributing to the mindset that patients might be generally overtreated. The USPSTF notes that the potential benefit of screening is possible because treatment options can reduce the risk of clinical progression and metastatic disease and may reduce prostate cancer mortality. The draft statement also suggests that men who are not able or willing to tolerate treatment should not be screened in the first place.

Consider radiation therapy specifically. It is a common, proven effective and generally successful prostate cancer treatment, but there are associated risks. Rectal pain, sexual dysfunction, urinary incontinence, and reduced bowel function are the most serious side effects that are often a result of unnecessary radiation exposure to the organs near the prostate. USPSTF notes more than half of men who have radiation therapy experience long-term sexual impotence, and up to one in six men experience long-term bothersome bowel symptoms including bowel urgency and fecal incontinence. The risk for similar complications can be more severe with surgery. About one in five men who have a radical prostatectomy develop long-term urinary incontinence, and more than two in three men experience long-term sexual impotence. These side effects can be life-changing, and in many cases are associated with psychological challenges.

Reducing the risk for these complications has the potential to provide relief for the patient, family, and physician. It is an area of extreme unmet need in prostate cancer treatment. And new medical technology specially designed to address treatment complications is beginning to emerge. For example, using a gel-like barrier to create space between the prostate and surrounding tissue may limit the impact of radiation on those organs.

*After radiotherapy was complete, control patients experienced a clinically significant (1X MID) decline in bowel, urinary and sexual QOL 8 times more often than SpaceOAR patients.1,2

For decades, clinicians have called for more advanced medical technology to mitigate the risk of treatment complications. In their latest recommendation, the USPSTF appears to emphasize the need for safer approaches to treatment in order to improve quality of life, specifically stating the need to refine active prostate cancer treatments to minimize harm. If there was a possibility that prostate cancer treatment was not associated with the risk for side effects, would PSA-based screening become less controversial over time? With a lower risk of complications, perhaps prostate cancer screening and treatment will become a total benefit to both patients and medical professionals in the years ahead.

1) Hamstra D, et al. Continued Benefit to Rectal Separation for Prostate RT: Final Results of a Phase III Trial. Int J Radiat Oncol Biol Phys; Dec. 2016 DOI

2) Hamstra D, et al. Evaluation of sexual function on a randomized trial of a prostate rectal spacer. J Clin Oncol 35, 2017 (suppl 6S; abstract 69)