About a year ago I reviewed the controversies of prostate cancer screening, especially the conundrum that we still don’t know whether finding prostate cancer early saves any lives. I concluded by citing the US Preventive Services Task Force (USPSTF) recommendations that the evidence is insufficient to recommend for or against screening for prostate cancer in men age 50 to 75. The USPSTF recommends against screening men older than 75 as the evidence suggests that harms outweigh benefits in these men.
What does screening for prostate cancer mean? There are two tests that are used to test for prostate cancer. One is a blood test called prostate specific antigen (PSA). The second is the not-always-popular digital rectal exam (DRE) in which a physician physically palpates the prostate in an attempt to feel an abnormality.
In contrast to the USPSTF, the American Cancer Society (ACS) has traditionally recommended more aggressive prostate cancer screening than was strictly supported by the evidence. This week, the ACS issued revised prostate cancer screening guidelines that better reflect the current uncertainties in the science. The new guidelines are much closer to the USPSTF recommendations.
The major changes in the new ACS guidelines are:
- A discussion with the patient explaining that the benefits of screening are uncertain and explaining the possible benefits and risks of screening should occur before screening is performed.
- For men who choose to be screened for prostate cancer, DRE is now optional. Screening can occur with a PSA with or without DRE.
- For men who choose to be screened for prostate cancer and who have a PSA less than 2.5, screening can occur every two years rather than annually.
I understand that for many of my patients avoiding the DRE will be the highlight of their annual exam. But the bigger point that these guidelines struggle with is the fact that we have no idea whether or not we should be testing men for prostate cancer. Even worse, we are sure that some of the men who will be tested will be found to have prostate cancer and will be harmed by side effects of the subsequent treatment much more than their prostate cancer would have hurt them.
We will have better studies in the next few years that will attempt to answer if prostate cancer screening saves lives. In the meantime we have to make difficult decisions in the absence of adequate information.
American Cancer Society Revised Prostate Cancer Screening Guidelines: What Has–and Hasn’t—Changed
Los Angeles Times article: Education should accompany prostate screening, new guidelines say
Wall Street Journal Health Blog post: New Prostate Cancer Guidelines: Routine Screening Still Unneeded
My last post about prostate cancer screening: Screening for Prostate Cancer May Harm More than Help