For nearly a quarter-century, doctors have ordered annual PSA tests for men of a certain age to screen for prostate cancer, despite a lack of evidence that its benefits outweigh the risks — especially when tiny, slow-growing tumors were detected.
But the landscape appears to be changing. While questions about PSA screening remain, physicians increasingly recognize the need to discuss both its harms and benefits with patients.
The U.S. Preventive Services Task Force shook up the status quo last July when it advised against using the simple blood test, which measures levels of a protein called prostate specific antigen, with average-risk men of any age who had no prostate cancer symptoms. That recommendation prompted a backlash from urologists, who argued that screening saves lives, but gave pause to primary care doctors.
In recent weeks, though, urology and internal medicine groups have published surprisingly similar directives.
"I would say it's a shift toward a more targeted screening approach rather than a one-size-fits-all screening approach," said Dr. H. Ballentine Carter, a Johns Hopkins urologist, of the American Urological Association guidelines released May 3 and developed by a committee he chaired. The international association has more than 19,000 members worldwide.
Carter's committee noted that the greatest benefit appears to be for those 55 to 69 but urged that men in that age group discuss the pros and cons with their doctor before deciding whether to proceed. For those who opt for screening, waiting at least two years between tests could minimize its harms —namely false positives and the detection of slow-growing tumors that wouldn't have caused any symptoms — while preserving most benefits.
Similarly, the American College of Physicians, representing internists, released guidelines April 9 advising members to discuss the test's "limited benefits and substantial harms" with patients 50 to 69 years old and let them decide.
Both groups agreed that doctors should not screen men younger or older than their guidelines' age range or those expected to live less than 10 to 15 years because of other health conditions.
An elevated PSA level doesn't necessarily signify prostate cancer, but it can trigger a cascade of tests and treatments that could be riskier than the disease itself, potentially causing impotence, incontinence or even death from prostate cancer surgery.
These concerns are among the reasons Dr. Michael Albert, a Hopkins internist, said he began to change his approach even before these recent recommendations. "It used to be much easier for me to click on the PSA button and order it," said Albert, medical director of the East Baltimore Medical Center, part of Johns Hopkins Community Physicians.
Dr. Kenny Lin, a family physician, called the informed-consent approach "a cop-out." Simply by raising the subject of screening, doctors push patients toward it, said Lin, who, as a medical officer at the Agency for Healthcare Research and Quality, wrote the evidence review on which the Preventive Services Task Force based its recommendation against screening. So, said Lin, now on the faculty at the Georgetown University School of Medicine, "I don't bring it up necessarily."
Meanwhile, the American Association of Clinical Urologists, whose website said its membership includes 45 percent of U.S. urologists, warns in a statement that the recently announced guidelines could leave the impression that early detection of prostate cancer is no longer needed.
The Preventive Services Task Force and the urological association guidelines committee do agree, though, that one life is saved for every 1,000 men screened.
"There's really no doubt [it] saves lives," said Dr. William Nelson, a medical oncologist and urologist who directs Hopkins' Sidney Kimmel Comprehensive Cancer Center.
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The death rate from the disease has been declining since it peaked 20 years ago, although it isn't clear how much is due to PSA screening and how much to improved treatment. Still, Nelson acknowledged, "a lot more men die with prostate cancer than will ever die of it. The greatest threat to their health and happiness is attempts to treat them."
Since the 1990s, screening has led to a diagnosis of early-stage prostate cancer in more than a million U.S. men who probably would never have developed symptoms. More than nine out of 10 of them chose aggressive treatment.
Mark Humphrey, now 71, a retired General Electric executive, lived in western Massachusetts when a 2006 test showed his PSA had nearly doubled to 3.5. Although still in the normal range below 4, the rapid increase spurred his doctor to refer him to a urologist for a biopsy, which revealed abnormal cells.
But his cancer appeared unlikely to be aggressive. That information, coupled with memories of his late brother-in-law's experience with incontinence and impotence after surgery, led Humphrey to pass on aggressive treatment.
So Humphrey, who now lives in Baltimore, enrolled in the world's first prostate cancer "active surveillance program," which Carter directs at Hopkins. Instead of treating Humphrey's disease, Carter is keeping an eye on it, with PSA testing and a rectal exam every six months.
Approximately 1,000 men have chosen surveillance since the program launched more than 16 years ago. By following participants, Carter said, he and his colleagues hope to learn more about what distinguishes slow-growing from aggressive cancers.
Kaiser Health News (www.kaiserhealthnews.org) is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communications organization not affiliated with Kaiser Permanente.