Doctors group questions prostate cancer screening

The American College of Physicians (ACP) became the latest group to ask doctors to be clear about the limited benefits and “substantial harms” of prostate cancer screening before offering their male patients a prostate-specific antigen (PSA) test.

The ACP’s guidance statement, published Monday in the Annals of Internal Medicine, also explicitly recommends against screening men younger than 50, older than 69 or with less than 10 to 15 years to live.
Men in their 50s and 60s may weigh the potential benefits and harms of PSA testing differently, which is why the idea of shared decision-making between patients and their doctors is so critical, said the ACP’s Dr. Amir Qaseem.

“It’s important to sit down and explain everything to the patient and then if someone wants to be screened, that’s okay,” Qaseem told Reuters Health.

The concern with screening is that PSA tests catch some cancers that never would have affected a man’s life because they are so small and slow-growing - yet treatment can cause side effects such as incontinence and impotence.

And there’s still disagreement about whether regular screening saves a significant number of lives.

Organizations including the U.S. Preventive Services Task Force (USPSTF), a government-backed panel, have come out against PSA testing for average-risk men in recent years - and created controversy in the process (see Reuters Health story of April 25, 2012 here:).

The American Urological Association, on the other hand, says the decision to undergo PSA testing should be individualized. Last year, the group criticized the USPSTF for doing “a great disservice by disparaging what is now the only widely available test for prostate cancer.”

“The AUA agrees that the decision to test for prostate cancer be made in the context of a detailed conversation between a man and his physician, and it is important to know what guidance is being provided to the medical community by leading medical groups,” a representative for that organization told Reuters Health in an email on Monday.

The representative declined to comment specifically on the ACP’s statement, adding that AUA will be releasing its own new guidelines shortly.

In the United States, about 239,000 men are expected to be diagnosed with prostate cancer in 2013, but far fewer - less than 30,000 - will die of it, according to the American Cancer Society.

In its statement, the ACP said that among men ages 50 to 69, doctors should base their screening decision on the patient’s risk for prostate cancer, his general health and preferences and on a discussion of the potential benefits and harms of screening. Doctors should not test men “who do not express a clear preference for screening,” the group added.

“There may be situations where patients don’t really know what to do or may not be able to decide, and in that case, you don’t screen,” Qaseem said.

“The probability of somebody dying from prostate cancer is very low,” he added. “There’s a small potential benefit (to screening)… and the harms are very significant.”

Dr. David Bronson, president of ACP, agreed that current PSA testing has limitations. Several refined prostate cancer tests are coming to market soon, the New York Times reported late last month:.

“This is a great opportunity for innovation,” Bronson told Reuters Health.

“We need a new refined testing approach for this disease that will yield better, more accurate diagnoses.”

SOURCE: Annals of Internal Medicine, online April 8, 2013

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