The American Cancer Society on Thursday issued new guidelines recommending that all men ages 50 to 69 undergo prostate cancer screening using a blood test every two years.
Black men and those with a strong family history of prostate cancer should start annual screening at 45, the guidelines said.
Universal screening for prostate cancer, which accounts for about 2.5 percent of all deaths among U.S. men, has long been a subject of controversy. The evidence of the benefits of regular testing of blood levels of prostate specific antigen, or P.S.A., is somewhat limited. And there are well-documented harms associated with diagnosing and treating all prostate cancers, which are typically slow growing and may not ever cause issues in men who have them.
The new guidelines diverge from earlier recommendations that patients and physicians decide together about screening, based on careful consideration of the risks and benefits and patients’ values.
“This is truly a reversal,” said Dr. Philipp Dahm, a professor of urology at the University of Minnesota who was not involved in the guidelines.
The A.C.S. said it was updating its guidance based on new evidence and changes in how doctors monitor and treat prostate cancers.
While experts agreed with the rationale for the update, some worried that the guidelines would lead doctors and patients to default to screening, rather than having nuanced conversations about its pros and cons. That could lead men to unnecessarily undergo screening, biopsies and treatment like radiation and surgery, which can leave men with erectile dysfunction, urinary incontinence and bowel problems.
“The way that’ll be operationalized by most physicians is they’re just going to get this test on everyone,” said Dr. Alex Krist, a professor of family medicine at Virginia Commonwealth University who helped write another widely used prostate cancer guideline, issued in 2018 by the U.S. Preventive Services Task Force. “It’s a lot of harms still. And I’m not sure it’s going to have the benefits they’re predicting.”
How have the recommendations changed?
The previous A.C.S. guideline essentially left it up to men, starting at age 50, to make an informed decision with their doctors about whether to undergo a P.S.A. test, which is done with a blood draw. The U.S. Preventive Services Task Force, a government advisory panel that also makes screening recommendations, gave the same advice for men ages 55 to 69.
In 2023, less than 40 percent of men in that age group received a P.S.A. test.
In explaining the decision to recommend screening every two years, Robert Smith, senior vice president of early cancer detection science at the A.C.S., cited a new follow-up study on a randomized controlled trial of prostate cancer screening in Europe.
After 23 years, the risk of death from prostate cancer was 13 percent lower among men who were screened regularly compared with those who were not screened — meaning that about two deaths from prostate cancer were averted per 1,000 men screened.
The European study also found that prostate cancer screening reduced the incidence of metastatic disease. The A.C.S. published an analysis last year that suggested that advanced prostate cancer diagnoses rose after a recommendation not to screen.
Dr. Smith also pointed to changes in how doctors now manage a high P.S.A. result, including by conducting repeat testing and ordering a M.R.I. before proceeding to biopsy, and by actively monitoring low-risk cancers rather than treating them immediately. The guideline recommends that doctors ensure patients are informed about the risks and benefits of screening and give them the opportunity to raise any questions. (It does not recommend rectal exams as a primary way of screening.)
“Given the burden of disease and the fact that many men still want to undergo regular testing for prostate cancer, we felt it was important to be clear that prostate cancer screening does save lives,” Dr. Smith said. And, he added, “we have strategies right now that if they’re followed will significantly reduce the risk of harms.”
Why is the recommendation different for Black men?
Data show that Black men are about 1.7 times more likely than white men to be diagnosed with prostate cancer, and about twice as likely to die of it. Diagnoses in Black men also start to climb at an earlier age, Dr. Smith said, which is why the A.C.S. guideline recommends that they begin screening at 45.
Dr. Otis Brawley, a professor of oncology and epidemiology at Johns Hopkins University who has studied cancer disparities, said he understood the recommendation to begin screening earlier, but he wasn’t aware of data suggesting that prostate cancer behaves more aggressively in Black men.
The primary reason Black men have worse outcomes, he said, is because they have less access to high quality care. Research has shown that when Black men receive the same care in the same hospital system as white men, they have the same outcomes.
What about the risks of overdiagnosis and overtreatment?
Overdiagnosis occurs when cancers that would not have caused any harm during a person’s lifetime are diagnosed. Overtreatment occurs when those cancers are then treated unnecessarily — providing no benefit, at best, and causing harm, at worst.
These are real risks with prostate cancer screening; the U.S. Preventive Services Task Force has not backed universal screening because it concluded that the potential benefits did not outweigh these harms.
The task force estimated that for every 1,000 men offered screening, 100 true prostate cancers would be diagnosed — up to half of which would never grow, spread or become harmful. Most would be treated nonetheless, and 65 men would experience erectile dysfunction or urinary incontinence, while five men would still ultimately die from prostate cancer even after treatment.
Dr. Dahm of the University of Minnesota said the guidelines did establish guardrails to lessen these risks, including by recommending testing biennially and limiting testing to a core age group that was most likely to benefit.
What should I do if I have a high P.S.A. result?
The guidelines recommend that someone who has an elevated P.S.A. be retested, as other conditions can cause elevated levels. If the repeat test also produces an abnormal result, the A.C.S. recommends a M.R.I. in order to distinguish between low-risk cancers and high-risk cancers, which need to be confirmed via biopsy. Tumors that appear to be low risk can be treated with “active surveillance,” which can include P.S.A. testing, monitoring and biopsy.
