Posts Tagged ‘PSA guidelines’

PSA Testing For Prostate Cancer-New Recommendations For 2015

February 16, 2015

In 2012 the United States Task Force released guidelines for PSA testing for prostate cancer that stated that no man should be tested for prostate cancer with a PSA test since there was far too many man who were over-diagnosed and who had treatment and complications from the treatment and that the cancer was so slow growing that few men would die of their prostate cancers.

Two physicians’ groups are now recommending informed decision-making when it comes to screening for prostate cancer. This is in line with American Cancer Society guidelines for early detection of prostate cancer.

The American Urological Association (AUA), the leading organization representing urologists, is recommending more moderate use of prostate cancer screening tests.

In its new guidelines, the AUA recommends that men ages 55 to 69 discuss the benefits and harms of prostate cancer screening with their doctors before deciding whether to be screened. It recommends against screening for men younger than 55 who are at average risk, as well as for men 70 and older.

The American College of Physicians (ACP) released a similar guidance statement in April 2013. The ACP says men between the ages of 50 and 69 should discuss the limited benefits and substantial harms of the prostate-specific antigen (PSA) test with their doctor before undergoing screening for prostate cancer. The guideline says only men between the ages of 50 and 69 who express a clear preference for screening should have the PSA test.

These new recommendations are closer to those of the American Cancer Society and several other groups issued in recent years. The American Cancer Society recommends that men discuss the possible risks and benefits of prostate cancer screening with their doctor before deciding whether to be screened. The discussion about screening should take place starting at age 50 for men who are at average risk of prostate cancer and expect to live at least 10 more years. It should take place at age 40-45 for men who are at higher risk, this includes African-American men and men who have a father or brother diagnosed with prostate cancer.

The discussion with the doctor should include an explanation to men of the uncertainty of the PSA test, potential harms from the prostate biopsy and treatments such as surgery and radiation, and potential benefits of PSA screening. Use of this test should be a decision made by the individual patient in collaboration with his healthcare provider.

Some limitations of screening

Screening looks for disease in people who have no symptoms. The main goal of prostate cancer screening is to reduce deaths due to prostate cancer. But the studies showed that the number of men who avoided dying of prostate cancer because of screening after 10 to 14 years was very small.

And screening isn’t perfect. Sometimes screening misses cancer, and sometimes it finds something suspicious that turns out to be harmless. The PSA test often produces false-positive results. For example men with an enlarged prostate gland or men with an infection of the prostate gland can have an elevated PSA level. Also, there aren’t reliable tests yet to tell the difference between prostate cancer that’s going to grow so slowly it will never cause a man any problems, and dangerous or aggressive prostate cancer that will grow quickly. Treatments for prostate cancer can have urinary, bowel, and sexual side effects that may seriously affect a man’s quality of life.

Bottom Line: The PSA is not a perfect test. It is inexpensive and it is non-invasive. It is useful as a baseline test and can help a man decide if he should proceed to a biopsy or to have treatment for his cancer. A thorough discussion between the man and his doctor is the best recommendation that I can provide for all men who are concerned about prostate cancer.

Screening For Prostate Cancer-New Guidelines and One Doctor’s Advice

May 10, 2013

Prostate cancer is the most commonly diagnosed non–skin cancer among U.S. men. It can be life-threatening, and many men have cancer without knowing it. For those reasons, doctors sometimes look for prostate cancer in healthy men (screen for cancer) by measuring blood levels of prostate-specific antigen (PSA), a protein secreted by the prostate gland. High PSA levels can be caused by cancer and may lead a doctor to take a sample of prostate tissue to see whether cancer is present (biopsy). Most prostate cancer grows very slowly, however, and many men with prostate cancer die of other causes. Neither PSA testing nor prostate biopsy tells doctors with certainty which cases of prostate cancer are threatening and which require treatment. As a result, many men with slow-growing cancer have biopsies and treatment after PSA testing that they would not have needed if doctors had never tested them.

The value of the PSA test has recently come into question, however, with several studies suggesting it causes men more harm than good — spotting too many slow-growing tumors that, especially in older patients, may never lead to serious illness or death. In 2012, the U.S. Preventive Services Task Force, an influential government-appointed panel, advised against any routine use of the PSA test for prostate cancer in all men.

Since most urologists consider the Task Force’s guidelines and global ban on PSA testing far too stringent For that reason, a group of experts at the recent 2013 American Urologic Association’s annual meeting in San Diego recently recommended against annual testing and prostate biopsies at certain PSA levels, usually a level greater than 4.0ng\ml. It is possible that using the PSA test differently (for example, by testing less often) would still be useful but reduce the harms of unnecessary treatment such as urinary incontinence and erectile dysfunction that come from more frequent testing.

What are the new AUA recommendations? There are several ways of using the PSA test to help men make the diagnosis of prostate cancer while reducing the harms of testing. The first way is to stop screening after age 70 years because men older than 70 years tend to have higher PSA levels without having prostate cancer, or if they have cancer, it is usually the slow-growing variety and does not result in a cause of older men’s mortality. Another way to use the new guidelines included measuring PSA levels less frequently such as every two years in men whose levels are normal especially when the initial PSA levels are less than 1.0ng\ml. Finally, the doctor caring for older men might recommend that they have higher levels of PSA before recommending a biopsy and possible unnecessary treatment.

It is hoped that the new recommendations by the American Urologic Association will result in more personalized health management where discussions will take place between doctor and patient and where the risk of having prostate cancer and the age of the man are balanced against the value of screening.
The new AUA guidelines are more nuanced. The group does recommend against the PSA test for men under age 40 or for those aged 40 to 54 at average risk for prostate cancer.

The AUA says, however, that men aged 55 to 69 should talk to their doctors about the risks and benefits of PSA screening and make a decision based on their personal values and preferences.

Routine PSA screening is not recommended for men over age 70 or any man with less than a 10- to 15-year life expectancy.

The best evidence of benefit from PSA screening was among men aged 55 to 69 screened every two to four years. In this group, PSA testing was found to prevent one death a decade for every 1,000 men screened. The guidelines also said PSA screening could benefit men in other age groups who are at higher risk of prostate cancer due to factors such as race, i.e., African American men and men with family history of prostate cancer. These men should discuss their risk with a doctor and assess the benefits and potential harms of PSA testing.

Bottom Line: What do I recommend that you tell patients? I agree with the guidelines that men over age 70 probably do not need to be tested. Also men younger than age 50 do not need to be tested. The exception is African American men and men with a family history of prostate cancer. I would not test a man with multiple chronic conditions, which would decrease his life expectancy to less than 10 years. I would also suggest that men with very low PSA levels, i.e., less than 1.0ng\ml, be tested every two years.

Finally, the discussions between a patient and his doctor on the PSA test are extremely important. I suggest you ask the man if he gets a PSA test, would he submit to a prostate biopsy and if he has prostate cancer would he accept treatment for the condition? If the answer is no, then I would document this in the chart and not obtain the test.