American Cancer Society revises screening guidelines for prostate cancer

The American Cancer Society (ACS) recommends that men have more in-depth discussions about the benefits and risks of prostate cancer screening with their physicians, according to revised prostate cancer screening guidelines issued by the organization. The new guidelines reflect the controversy over prostate-specific antigen (PSA) screening and digital rectal exams (DREs) and whether early screening results in unnecessary treatments that can have serious side effects. Although these 2 tests...

The American Cancer Society (ACS) recommends that men have more in-depth discussions about the benefits and risks of prostate cancer screening with their physicians, according to revised prostate cancer screening guidelines issued by the organization.

The new guidelines reflect the controversy over prostate-specific antigen (PSA) screening and digital rectal exams (DREs) and whether early screening results in unnecessary treatments that can have serious side effects. Although these 2 tests can find prostate cancer early, they cannot determine if the cancers are slow growing or aggressive.

The ACS based its revised guidelines on two large studies--the U.S. Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial and the European Randomized Study of Screening for Prostate Cancer (ERSPC)--that examined whether prostate cancer screening with the PSA blood test and DREs saves lives.

The PLCO trial included more than 76,000 men who were randomized to receive usual care or annual PSA tests for 6 years and DREs every year for 4 years. Little difference in prostate cancer death rates was seen between the 2 groups at 7 years and again at 10 years of follow-up.

The ERSPC included 182,000 men who were randomized to either a control group or a screening group; the latter involved PSA tests on average every 4 years and a DRE twice during that period of time. Results after 9 years of follow-up showed that screening reduced the rate of prostate cancer death by 20%. The researchers determined that the number of men needed to treat to prevent 1 death from prostate cancer was 48.

The ACS is now recommending that physicians more heavily involve patients in the decision of whether to get screened for prostate cancer.  According to the new guidelines, men should be given decision-making tools to help them reach an informed conclusion about testing.

Specifically, the new guidelines recommend that men with no symptoms of prostate cancer who are in relatively good health and can expect to live at least 10 more years have the chance to make an informed decision with their physician about screening after learning about the uncertainties, risks, and potential benefits associated with prostate cancer screening. Physicians should begin these discussions with male patients starting at age 50 years.

Prostate screening should not be offered to men with no symptoms who are not expected to live more than 10 years (because of age or poor health) because the risks of treatment outweigh the benefits, according to the revised guidelines.

Men at high risk--African-American men and men who have a father, brother, or son diagnosed with prostate cancer before age 65 years--should start discussing risks and benefits of screening earlier, at age 45 years, while men at higher risk--those with multiple family members affected by the disease before age 65 years--should have these conversations even earlier, at age 40 years.

Among men who choose to undergo screening, the revised guidelines also make the DRE optional and offer an extended time interval between screenings for those with low PSA levels.

Not all organizations agreed with the ACS revised guidelines. The American Urological Association concurred with the recommendation to emphasize informed consent, but it said the ACS position may not completely explain the potential benefits of an individualized approach to assessing the risks and benefits of early detection.

Specifically, the AUA said the use of population-based cut points while ignoring other individual risk factors (ie, age, ethnicity, family history, previous biopsy characteristics) may not give patients the best assessment of their risks, including the risk of high-grade disease.

According to the AUA, all men with a life expectancy of 10 years or more should have a baseline PSA test at age 40 years. Rescreening intervals for each patient should be based on PSA and, in certain instances, on its change over time. The need for prostate biopsy should not be based just on elevated PSA and/or abnormal DRE but should consider multiple factors, such as free and total PSA, patient age, PSA velocity, PSA density, family history, ethnicity, prior biopsy history, and comorbidities.