Prostate Cancer Screening
Guidelines Revised

Aug. 06, 2008 — Just-released prostate cancer screening guidelines are likely to cause comment and concern in the medical community in coming weeks and months.

The updated government guidelines take a dim view of prostate cancer screenings at any age and flatly recommend against them entirely for men over 75.

The new recommendations were published this week in the Annals of Internal Medicine.

Prostate cancer is the most common non-skin cancer in the United States, affecting one of every 6 men. Common screening tests are the prostate-specific antigen (PSA) blood test, which tests for protein blood levels, and a digital rectal examination (DRE), which can detect abnormal growth of the gland itself. But neither test can distinguish between prostate cancers that will become life-threatening and those that will grow so slowly that most men die from other conditions and not from prostate cancer.

Dubious Benefit for Older Men
The over-75 rule "is much more explicit than any recommendation out there right now" for using the PSA test, says Dr. Michael L. LeFevre, a member of the US Preventive Services Task Force that is updating its 2002 report.

"The time frame is that the benefit, if there is any, from screening, is 10 years," Dr. LeFevre, a professor of family and community medicine at the University of Missouri, adds. "The average life expectancy for men over 75 years is less than 10 years, so screening them can do more harm than good."

For the same reason, men under 75 with serious health problems whose life expectancy is less than 10 years should not get screened, the task force report says.

Even for younger men with no health problems, "there is uncertainty about whether the benefits exceed the harm, based on existing evidence," Dr. LeFevre says

"Most of the harms are related to treatment rather than screening," Dr. LeFevre says. Surgery and other prostate cancer treatment can cause impotence and damage urinary function and bowel function, he adds.

Men Should Decide with Their Physicians
"Men under the age of 75 should try to make an informed choice at this time," Dr. LeFevre says of screening tests. "The current evidence is not enough for us to know the balance between benefit and harm."

Current data show that a third of the men over 75 in the United States receive PSA tests, the task force report says.

A man should talk to his physician about prostate cancer screening, Dr. LeFevre says. "That discussion should occur before screening occurs and should include what the test does and does not mean, the consequences of finding cancer, and the uncertainty about whether benefit exceeds harm, based on current evidence," Dr. LeFevre says.

Medical organizations make varying recommendations about prostate cancer screening. The American Cancer Society (ACS) position is that a test should be offered yearly to men with a life expectancy of at least 10 years, starting at age 50. Men at higher risk, such as those who have one close relative with the cancer, should begin testing at age 45, and those with several affected close relatives can have a first test at age 40, the ACS says.

Many older men will still want prostate cancer screening, says Dr. Susan F. Slovin, an associate attending physician who specializes in prostate cancer at Memorial Sloan-Kettering Cancer Center in New York. "These patients are very informed, and their view will be at odds with the recommendations," she says. "These are not the 75-year-olds of 50 years ago. These are physically younger people, still actively functioning sexually in many cases."

Change May Meet Resistance
The new guidelines "will not sit well with oncologists and a lot of people," continues Dr. Slovin. "As medical oncologists, we are always trying to be one step ahead of the cancer. We are trying to intervene earlier and identify patients who are at risk. We always want to intercede, to do something."

Dr. Slovin sees the screening pendulum swinging in a direction opposite to that of the new recommendation. "We are starting to make recommendations that some people be screened by the age of 35," she says.

But not everyone agrees with that assessment. Dr. Otis W. Brawley is a prostate cancer epidemiologist and chief medical officer of the ACS. He calls the new guidelines "right on target."

"The American Cancer Society since 1997 has been against mass screening," Dr. Brawley says. "But within the physician-patient relationship, a test should be offered to the patient, with the patient informed of the potential risks and potential benefits, so he can make an informed decision."

The ACS does not recommend against prostate cancer screening for men over 75, "but we are in the process of re-evaluating our recommendations for men of all ages," Dr. Brawley says.

Always consult your physician for more information.