New guidelines released Wednesday stress the importance of telling patients about the uncertainties, risks and benefits of getting screened for prostate cancer, a reflection in part of conflicting data about whether the tests themselves save lives.
Much about the guidelines remains unchanged since the American Cancer Society last updated them in 2001. The group still advises that men begin discussing prostate cancer screening with their doctor at age 50 if they are not at high risk for the disease, and earlier if they are at risk.
But the new guidelines for the first time include detailed recommendations on information that health care providers should discuss with patients; advise that doctors decide whether to test men who are not sure if they want to be tested; and say that men whose prostate-specific antigen, or PSA, tests show levels below a certain threshold could be tested every two years rather than annually.
"Men and their primary-care physicians need to have a much more active role in discussing the pros and cons of screening," said Dr. Andrew Salner, director of the Helen & Harry Gray Cancer Center at Hartford Hospital and a member of the committee that wrote the new guidelines.
The conversations would vary depending on the patient. For a 70-year-old man with no family history of prostate cancer, a doctor might point out that even if he is diagnosed with prostate cancer, physicians might recommend active surveillance rather than treatment. But for a man who is African American or who has a father or brother with prostate cancer, two risk factors for the disease, the doctor might be likely to recommend regular testing.
The committee's recommendations reflect uncertainty about the role of PSA testing in reducing mortality from prostate cancer. Some doctors argue that early diagnosis, made possible with PSA tests that became available in the 1990s, has led to more early treatment, saving lives. Others point to advances in treatment itself that have occurred.
"I think everybody felt that there does not exist the same kind of compelling data that we have with breast cancer, where we know that mammograms save lives, there's no doubt about it," Salner said. "We just don't have that same kind of compelling data that PSAs save lives."
Two recent randomized studies offered conflicting results. One, conducted in Europe, found that men who were screened had a lower rate of prostate cancer death. The other, a project of the National Cancer Institute, found that screening men six times a year led to more diagnoses of prostate cancer than among men who were screened once a year, but did not lead to fewer prostate cancer deaths.
Although PSA testing can lead to early diagnoses of aggressive cancers, it can also catch cancers that are less aggressive and, if not detected, might not have caused problems during a man's lifetime.
In a written statement, Dr. Andrew Wolf, a professor at the University of Virginia Health System and chairman of the committee that wrote the recommendations, said the potential benefit of early detection "must be weighed against the serious risks associated with subsequent treatment, particularly the risk of treating men for cancers that would not have caused ill effects had they been left undetected."
The guidelines are not meant to recommend against PSA testing, but are intended to offer a more nuanced, individualized picture, Salner said.
"Nobody is saying to abandon PSA screenings for sure," Salner said. "I think there's still a sense that PSA screening is a good thing to do. It's not necessarily the right thing to do for every possible setting."
Not everyone agrees with all the new recommendations.
Dr. Anton Bueschen, president of the American Urological Association, said in a written statement that the new cancer society guidelines might cause confusion for patients. "The AUA feels there is no single PSA standard that applies to all men, nor should there be," he wrote.
The urological association recommends that all men with a life expectancy of at least 10 years have a baseline PSA test at age 40, and that doctors should determine how often the patient should be screened again based on the PSA.
Dr. Jeffrey Steinberg, chairman of surgery at St. Francis Hospital and Medical Center in Hartford and medical director of the Curtis D. Robinson Men's Health Institute, called the guidelines reasonable in general, but he took issue with parts of them.
"I don't want people to interpret this as saying, 'Oh, we don't have to worry about prostate cancer,'" he said.
In particular, Steinberg said, he thinks African American men, who have higher rates of prostate cancer and higher rates of dying from it, should be tested beginning at age 40, rather than 45, as the cancer society guidelines recommend.
Steinberg also took issue with the randomized studies of PSA testing, questioning their methodology and cautioning against applying their conclusions to all groups. Not enough African American men were included in the studies to apply the studies' conclusions to them, he said.
It will largely be up to primary-care doctors to have conversations with patients about testing, Steinberg said, although he said that could be challenging given the constraints they already face.
"Operationally, especially with the shortage of primary-care doctors and the ever-limited time with patients, I think that it's going to be hard for the primary-care physicians to uniformly implement protracted discussions, but I think that they have to make an effort in talking about it," Steinberg said.
SOURCE: The Hartford Courant - Arielle Levin Becker
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