The CUA: Advocating for our patients

The Canadian Task Force on Preventative Health Care’s (CTFPHC) position on prostate cancer screening has not been updated since 2014.¹ They continue to recommend against prostate-specific antigen (PSA) screening in men and do not recommend rectal examinations. Moreover, not even a discussion on the merits of PSA screening with the patient is considered. Since the CTFPHC has significant influence on primary care and the health of the general population, such recommendations require frequent evidence-based review.

To their credit, the U.S. Preventative Services Task Force (USPSTF) has reviewed their position and changed their stance on prostate cancer screening in 2018, from a blanket D recommendation against screening to one that recommends a pro/con discussion with the patient, level C.² The USPSTF withdrew its previous objections and advised personalized decision-making for screening men aged 55–69 years. They cited recent clinical trial evidence showing that screening had a greater benefit in reducing prostate cancer mortality than was previously recognized, as well as a benefit in preventing metastatic disease. Overall, they concluded, with moderate certainty, that there was a small net benefit for screening. Their document reads: “The USPTF recommends counselling men, 55–69 years, on the risks and potential benefits of undergoing periodic PSA-based screening for prostate cancer. Clinicians should not screen men who, after adequate informed consent, do not express a preference for screening.”

Of course, the Canadian Urological Association (CUA) updated its guideline in 2017³ and then again in 2022,⁴ stating: “The CUA suggests offering PSA screening to men with a life expectancy >10 years. The decision of whether or not to pursue PSA screening should be based on shared decision-making after the potential benefits and harms associated with screening have been discussed.”

With respect to provincial positions, the Ontario Ministry of Health recommends against systematic mass screening.⁵ Its guideline reads: “PSA determination should not be used as a population-wide mass screening test for the early detection of prostate cancer in asymptomatic males,” but goes on to state that an informational brochure has been developed to assist men between the ages of 50–75 with a life expectancy of >10 years in making an informed decision on PSA testing.

The Quebec Collège des médecins goes a little further and recommends that primary care physicians should initiate a discussion regarding the pros and cons of prostate cancer screening with periodic serum PSA tests,⁶ stating: “Le Collège des médecins du Québec recommande aux médecins de discuter avec leurs patients âgés de 55–70 ans et qui ont une espérance de vie de 10 ans ou plus des avantages et des inconvénients du dépistage par l’APS combiné au toucher rectal, et de s’assurer qu’ils ont bien compris les enjeux avant de prendre la décision de faire ou de ne pas faire le dépistage.”

It is clear the CTFPHC recommendations should be reviewed and based on the evidence, revised to be more in-line with those described above.

This is exactly the type of advocacy role the new CUA Advocacy Office will undertake. The CUA has appointed Dr. Hassan Razvi, Past President, as the interim Chief Advocacy Officer until an officer is elected at the 2023 annual general meeting. On behalf of the membership, I thank Dr. Razi for taking on this position and organizing our advocacy efforts. The first order of business is for the CUA to join the effort in requesting an immediate evidence-based review of the CTFPHC recommendation for prostate cancer screening.