PSA advice? Talk to your doctor.
Edition: September 2013 - Vol 21 Number 09
It may sound like one of those annoying Rx commercials you see on TV, where the voice-over says, “Talk to your doctor.” But that’s the bottom line for asymptomatic men considering a prostate-specific antigen (PSA) test to detect prostate cancer, according to recently released guidelines from two clinical organizations.
In April, the American College of Physicians released a prostate cancer screening guideline suggesting that men between the ages of 50 and 69 should discuss “the limited benefits and substantial harms of the prostate-specific antigen test with their doctor before undergoing screening for prostate cancer.”
One month later, the American Urological Association issued its new clinical guidelines on prostate cancer screening, recommending that men ages 55 to 69 who are considering prostate cancer screening “talk with their doctors about the benefits and harms of testing and proceed based on their personal values and preferences.”
The guidelines follow by about a year a recommendation by the U.S. Preventive Services Task Force that men altogether avoid routine PSA screening for prostate cancer. In that recommendation, published March 2012, the Task Force concluded that PSA screening leads to overdiagnosis and overtreatment, and that “the benefits of PSA-based screening for prostate cancer do not outweigh the harms.”
American College of Physicians
The American College of Physicians first issued guidelines for prostate cancer screening in 1997. Its most recent statement is an assessment of guidelines developed by other organizations. That’s because ACP believes it is more valuable to provide clinicians with a review of available guidelines rather than develop a new one on the same topic, when multiple guidelines are available on a topic, or when existing guidelines conflict, according to a spokesman.
ACP recommends against PSA testing in average-risk men younger than 50, in men older than 69, or in men who have a life expectancy of less than 10 to 15 years.
“A small number of prostate cancers are serious and can cause death,” said Amir Qaseem, MD, PhD, MHA, FACP, director, clinical policy, American College of Physicians, in a statement following the release of the guidelines. “However, the vast majority of prostate cancers are slow-growing and do not cause death. It is important to balance the small benefits from screening with harms, such as the possibility of incontinence, erectile dysfunction, and other side effects that result from certain forms of aggressive treatment.”
In its recommendations, the ACP pointed to “substantial harms” associated with prostate cancer screening and treatment, including:
• Problems interpreting test results. The PSA test result may be high because of an enlarged prostate but not because of cancer. Or, it may be low even though cancer is present.
• If a prostate biopsy is needed, it is not free from risk. The biopsy involves multiple needles being inserted into the prostate under local anesthesia, and there is a small risk of infection or significant bleeding, as well as a risk of hospitalization.
• If cancer is diagnosed, it will often be treated with surgery or radiation, which carry risks, including a small risk of death with surgery, loss of sexual function (approximately 37 percent higher risk), and loss of control of urination (approximately 11 percent higher risk) compared to no surgery.
American Urological Association
Under development for nearly two years, the AUA’s clinical guidelines state:
• PSA screening in men under age 40 years is not recommended.
• Routine screening in men between ages 40 to 54 years at average risk is not recommended.
• For men ages 55 to 69 years, the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in one man for every 1,000 men screened over a decade, against the known potential harms associated with screening and treatment. For this reason, shared decision-making is recommended for men age 55 to 69 years who are considering PSA screening, and proceeding based on patients’ values and preferences.
• To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce overdiagnosis and false positives.
• Routine PSA screening is not recommended in men over age 70 or any man with less than a 10-to-15-year life expectancy.
“While much of the media coverage concerning the guidelines has been accurate, some outlets have mistakenly stated that the AUA has changed its position and is now recommending against prostate cancer screening in all men at risk for this common disease,” said the association in an “Open Message” several days after release of its guidelines.
“In fact, this is not at all what the guidelines state. Compared to our 2009 best practice policy document, the guidelines do narrow the age range in which informed decision making around PSA screening should be offered to men at average risk for prostate cancer, but they do not make a blanket statement against screening, as some have implied. Importantly, the guidelines only apply to men at average risk. The guidelines do not apply to symptomatic men or those at high risk for disease (men with a family history or of African-American race), who are encouraged to discuss their individual case with their doctor, regardless of their age.”
The AUA acknowledged the guidelines reflect changes made in response to recent studies on screening. Those changes include:
In men age 40-54 at average risk for the disease, screening, as a routine practice, should not be encouraged. “Simply put, the evidence for the benefit for screening in this age range was limited while the quality and strength of the evidence regarding the harms of screening was high,” said the association. “This does not mean that we are recommending AGAINST screening; it simply means that there is insufficient evidence to support routine screening in this population at this time.”
Routine screening is not recommended for men over age 70 or those with less than a 10-to-15-year life expectancy. “However, the guidelines acknowledge that some men over age 70 in excellent health may benefit from screening. In this setting, the guidelines suggest that a discussion of the unique risks and benefits of screening in older men occur.”
In men age 55-69, AUA still strongly recommends shared decision-making and screening based on a man’s values and preferences. But the new guidelines recommend biennial screening to reduce the potential harms of screening.
“Additionally, it should be noted that the AUA remains in disagreement with the U.S. Preventive Services Task Force in recommendation against prostate cancer screening in all men, regardless of age or risk, without even considering a discussion of the risks and benefits of screening,” said the association in its Open Message. “The AUA continues to support a man’s right to be tested for prostate cancer – and to have his insurance pay for it, if medically necessary.”
PSA decision usually not a shared one
New recommendations from the American Urological Association and the American College of Physicians recommend that doctors and patients together weigh the pros, cons and uncertainties of prostate-specific-antigen (PSA) screening. Yet a recent study in the Annals of Family Medicine suggests that shared decision-making might be more fiction than fact.
A nationally representative sample of 3,427 men aged 50 to 74 years participating in the 2010 National Health Interview Survey responded to questions on the extent of shared decision-making (past physician-patient discussion of advantages, disadvantages, and scientific uncertainty associated with PSA screening), PSA screening intensity (tests in past five years), and sociodemographic and health-related characteristics. (The National Health Interview Survey gathers data on a broad range of health topics collected through personal household interviews. The U.S. Census Bureau serves as the data collection agent for the National Health Interview Survey.)
Nearly two-thirds (64.3 percent) of men reported no past physician-patient discussion of advantages, disadvantages, or scientific uncertainty (that is, no shared decision making); 27.8 percent reported discussion of one to two elements only (partial shared decision-making); and 8 percent reported discussion of all three elements (full shared decision-making). Nearly one-half (44.2 percent) reported no PSA screening, 27.8 percent reported low-intensity (less-than-annual) screening, and 25.1 percent reported high-intensity (nearly annual) screening.
Absence of shared decision-making was more prevalent among men who were not screened. Eighty-eight percent of non-screened men reported no shared decision-making compared with 39 percent of men undergoing high-intensity screening.
To view the study, go to http://www.annfammed.org/content/11/4/306.full?sid=36f32ae5-1449-488d-944f-56bb5361ec5d