Months after a government task force rocked the medical community by changing guidelines for mammogram screening, the American Cancer Society ("ACS") sent a similar shockwave to men. The ACS is urging doctors to make clearer to men that the test used to screen for prostate cancer (a blood test known to most as the "PSA" test) has limits and may lead to unnecessary treatments that do more harm than good.
In fairness to the ACS, it has not recommended routine PSA screening for most men since the mid-1990s. As a result, different doctors have employed different philosophical approaches to the issue of prostate cancer screening. Annually, millions of men elect to have their blood tested for the level of the prostate specific antigen. This latest position from the ACS, however, urges physicians to warn of the limitations of the PSA blood test. The ACS also offers that the digital rectal exam that has been standardly employed for as long as anyone can remember should be an option rather than part of a standard screening. Why the sudden change?
American men have long been urged to have prostate cancer screenings, but over time studies have suggested that most cancers found are so slow-growing that most men could have avoided treatment. A phrase that holds a lot of truth is that most men will die with prostate cancer not from prostate cancer. The consequences of treatment can be severe, incontinence or impotence. With the benefit of long-term data, many believe that changes are required.
The ACS is perhaps the most influential group in giving screening advice. Its new guidance on prostate cancer urges doctors to:
- Discuss the pros and cons of testing with their patients, including giving them written information or videos that discuss the likelihood of false test results and the side effects of treatment.
Stop giving the rectal exam as a standard prostate cancer screening because it has not clearly shown a benefit, though it can remain an option.
- Use past PSA readings to determine how often follow-up tests are needed and to guide conversations about treatment.
Prostate cancer is the most common non-skin cancer in American men. An estimated 192,000 new cases and 27,000 deaths from it occurred last year in the United States.
But prostate cancer is a slow-growing cancer in many cases, and depending on a man's age, he may be more likely to die of something else. Major studies have suggested routine screening doesn't save lives and often leads to worry and unnecessary treatment.
The new cancer society recommendations could change how routine physical exams for many older men are conducted. About 41 percent of men 50 and older get annual prostate cancer screenings. Even though the cancer society doesn't recommend routine PSA tests, many doctors do it without even asking their patients. And there's little conversation about it unless the test gives a worrisome result. The new guidelines may spur doctors to talk to their patients earlier about the pros and cons of getting the test in the first place.
Prostate cancer screening became a medical mantra in the 1990s, thanks to the development of the PSA test. Some celebrities became advocates for routine testing, including former New York City Mayor Rudy.
But concerns about the value of routine screening increased after two large studies concluded screening for prostate cancer doesn't necessarily save lives, and noted any benefits can come at a high price.
The American Urological Association - a longtime proponent of regular screening - has backed off its call for annual tests after age 50. The group said men should be offered a baseline PSA test at age 40, with follow-ups at intervals based on each man's situation.
The group also has stood by the rectal exam as a standard part of screening, saying it can find cancer that the blood test does not.
The cancer society has been more cautious about regular screenings for some time. The organization last issued guidelines in 2001, which said merely that doctors should offer screening and discuss the risks and benefits.
The new guidelines back away even more, dropping the sentence that doctors should offer prostate screening. Instead, the society says some evidence indicates periodic screening can save lives but that there are significant uncertainties about the overall value of finding prostate cancer early. Screening should not take place, the new advice says, unless a patient is fully informed of the trade-offs.
Men at average risk should get detailed information around age 50, the society recommends. Men at higher risk, including African-Americans and men with a father or brother who had prostate cancer before age 65, should get the information beginning at age 45. Men with more than one close relative with prostate cancer before 65 should get such information at age 40.
For men who want to be screened regularly, the new guidelines recommend every other year if the PSA reading is less than 2.5, a measure of prostate specific antigen per milligram of blood. Annual tests are recommended for 2.5 or higher and a 4 suggests consideration of a biopsy.
This is a difficult issue with no clear conclusion to be drawn. Individual doctors will react to these recent guideline changes in different ways. Similarly, individual patients may react to the guideline changes and recent study results in different ways as well. For now, men should know there is a controversy here and discuss the controversy with their doctor. For what it is worth, the lawyers at Rosen Louik & Perry have handled numerous cases and obtained impressive verdicts and settlements in situations where prostate screening and treatment were provided at an unacceptable level. If you believe that you or a loved one may have received inadequate medical care, please call for a free consultation.