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ACP: PSA Screening’s Harms Outweigh Benefits
Frontline Medical News, 2013 Apr 08, MA Otto
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Expert Comment

Primary Care
David Rakel MD, FAAFP

To Order or Not to Order, Is That the Question?

The American College of Physicians reviewed the guidelines from the USPSTF, AUA, ACS, and ACPM and made the following recommendations for prostate-specific antigen (PSA) screening:

• In average-risk men, only order a PSA (if at all) for those between ages 50 and 69 years, and for those with a life expectancy exceeding 10 to 15 years.
• For high-risk men, consider a PSA at age 45.

So, who is at high risk for prostate cancer? A first-degree relative diagnosed before age 65 and African American men. Other risks include overweight, a diet high in dairy and red meat, inactivity, low level of vitamin D, and frontal baldness in African American men.

Since the specificity and sensitivity of PSA is so poor and therapy may cause more harm than benefit, it is difficult to know what to do with the screening result:

• If the PSA is < 1 μg/L, the evidence is pretty clear that the risk of prostate cancer is so low that the patient won’t need another screening anytime soon (for at least 5 years).
• If the PSA is > 10 μg/L, the patient should be referred to Urology.

The PIVOT (Prostate Cancer Intervention vs Observation Trial) trial showed a 13.2% reduction in all-cause mortality with treatment in those men with a PSA > 10 μg/L. Although there are no high-quality studies looking at the benefit of digital rectal exam, it can be helpful with decision-making. All guidelines stress the importance of active communication of benefits and harms with our patients. So, if you have a patient with a father with a history of prostate cancer (genetic risk), who is dark-skinned (higher risk of vitamin D deficiency), with little hair (more circulating dihydrotestosterone [DHT]), who enjoys dairy foods and red meat, and who is inactive and overweight (greater systemic inflammation), discuss the test. And, most of all, if you order it, don’t forget to use the results to influence positive behavior change. Ornish and colleagues showed that positive habits and lifestyles can inhibit the expression of prostatic oncogenes, and this confers very little harm!*

*Ornish D, Magbanua MJ, Weidner G, et al. (2008). Changes in prostate gene expression in men undergoing an intensive nutrition and lifestyle intervention. Proc Natl Acad Sci USA. 2008;105(24):8369-8374.

Dr. Barry Kramer

Dr. Barry Kramer

Dr. William Golden
PSA screening should not be done in men younger than 50 years or in those older than 69 years – and men between those ages should be offered the test only if they want to take it despite been told that they are more likely to be hurt by it than helped, according to new prostate-specific antigen screening guidelines from the American College of Physicians.

“A man’s chances of being harmed are much greater than his chances of benefiting from the PSA test,” caution the guidelines’ authors. Those harms include surgery that risks incontinence, impotency, and other problems to remove harmless tumors, the group said.

“Any absolute mortality risk reduction” from routine screening “is probably small to none, according to the guidelines. “The vast majority of prostate cancer is slow-growing and does not cause death.”

That news isn’t likely to surprise many doctors – PSA testing has been suspect for years, and ACP’s guidelines mirror and, in fact, are derived from those from other groups. But it might be a surprise to the general public.

There’s still “a lot of misperception about the accuracy and utility of the test,” because it’s been promoted until recently as a kind of “mammography for men,” noted Dr. William Golden, a professor of medicine and public health at the University of Arkansas.

With patient demand still high and many physicians fearing malpractice risk if they don’t screen, “it’s been a whole lot easier to just check the box and order the test,” Dr. Golden observed. “I think there are still a lot of PSAs being ordered [even for men] over age 75 [years].

“Statements like this from the ACP give doctors a little more ammunition to help educate patients that this is not a real strong diagnostic tool,” he said.

Dr. William Golden

To that end, the ACP has also published a one-page patient information sheet that explains the problems with PSA tests. The guidelines themselves include 10 talking points men need to hear before opting to be screened.

Men are open to the message, Dr. Golden said. “I say [to them], ‘Look, if you really want the test, I’ll give it to you.’ ” But he lets them know first that he and many other doctors don’t get themselves screened; that the test isn’t very sensitive or specific; and that it often leads to biopsies until something is found and operations regardless of therapeutic value.

“When they hear that kind of framework, a lot of patients don’t want to go near” it, Dr. Golden said. Instead, they say, “Look, I’d rather take my chances. I’d rather not have incontinence, I’d rather have sexual function, and I’d rather not have surgery for something that may or may not make a difference to my health.”

That discussion is exactly the approach ACP hopes to foster.

“The key is to talk with your patient and help determine what they value” – preserving continence, sexual function, and peace of mind, or gambling them on a tiny chance of catching a fatal tumor early, said the senior author of ACP’s guidelines, Dr. Paul Shekelle, director of the RAND Corporation’s Southern California Evidence-Based Practice Center. “Do not over-sell the screen-biopsy-surgery approach.”

Practice is still “probably tilted toward screening,” he said. “The ACP guideline is an attempt to steer this back.”

The conversation is much the same even for high-risk men – blacks and those with strong family histories of prostate cancer. But instead of starting at age 50 years, it should come at age 45 or 40. “Screening in high-risk men has not been demonstrated to be associated with different outcomes than screening in average-risk men,” the ACP guidelines note.

Up to a third of men are screened without their knowledge during routine physicals; that practice should end, the ACP also said.

The ACP derived its own recommendations from a review of those from the American College of Preventive Medicine, the American Cancer Society, the American Urological Association, and the U.S. Preventive Services Task Force. “ACP believes that it is more valuable to provide clinicians with a rigorous review of available guidelines, rather than develop a new guideline on the same topic when several guidelines are available,” it said.

The ACP found the USPSTF’s efforts the most rigorous; that group in 2012 recommended abandoning PSA screening.

“The one nuance [ACP] added is that in the [50-69 ] age range where there is a hint of benefit from one of the large trials, even for them the evidence of harm is much stronger than the evidence of benefit. I think [ACP] has the messaging correct,” said Dr. Barry Kramer, director of the National Cancer Institute’s Division of Cancer Prevention.

If they are performed, PSA tests should be conducted no more than every 4 years. “No evidence supports annual screening for prostate cancer,” the ACP guidelines note.

The potential benefit of screening is vanishingly small for men older than 69 years – and for those expected to live no more than 15 years – because prostate cancer isn’t likely to cause any problems in the time they have left, the guidelines explain. For men younger than 50 years, the downstream harms “such as erectile dysfunction and urinary incontinence carry even more weight relative to any potential benefit.”

Dr. Golden, Dr. Kramer, and Dr. Shekelle said they have no relevant financial disclosures.