Health
Chemoprevention one option in prostate cancer screening advice
■ Physicians warn that such discussions may crowd out messages about more effective health strategies.
By Victoria Stagg Elliott — Posted March 16, 2009
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Counseling about prostate cancer screening could become more complex, but some parts of the message are increasingly straightforward. For instance, the majority of men can be told they will be able to end testing after age 75, according to medical society guidelines and a study published in March and April.
The recommendations become complicated in regard to men who have decided to be screened annually with the prostate-specific antigen test but show no signs of prostate cancer. The American Urological Assn. and American Society of Clinical Oncology recommend that these patients be informed about the risks and benefits of chemoprevention, specifically with 5-alpha reductase inhibitor drugs such as finasteride. Studies have shown that these medications could reduce the chance of developing this disease.
This direction was included in a joint guideline published by the two organizations in the March Journal of Clinical Oncology and The Journal of Urology.
"The demonstrated effect of 5-ARIs in reducing prostate cancer incidence makes it reasonable to recommend them for use to prevent the disease," said Paul F. Schellhammer, MD, co-chair of the panel that wrote this paper and a past president of the American Urological Assn. "But, as with any drug, patients should discuss the risks and benefits with their physicians."
These drugs have several sexual side effects, including impotence and decreased libido, although data suggesting that this chemopreventive strategy may lead to more aggressive cancers have not panned out. It also is not known what impact these medications would have on men who are not being regularly screened or on prostate cancer mortality.
"We are not recommending that all men take 5-ARIs," said Barnett S. Kramer, MD, MPH, also co-chair of the guideline panel and associate director of disease prevention at the National Institutes of Health. "[These drugs] should be discussed with men who are actively being screened for prostate cancer. Screening in and of itself increases the risk of being diagnosed with prostate cancer by twofold. Finasteride decreases that risk by 25%."
But physicians expressed concern, because such discussions may distract patients from other preventive steps that make a more significant impact on a man's health. Taking this drug for chemoprevention is uncommon, and the decision to partake in regular PSA testing is already a tough one to help a patient navigate.
"Time with a doctor is a limited, valuable resource," said Remy R. Coeytaux, MD, PhD, associate professor of community and family medicine at the Duke University School of Medicine's Center for Clinical Health Policy Research in Durham, N.C. "This probably won't reach the level of high priority."
Screening is not forever
But those men who do opt for annual screening, with or without this drug, probably don't need to do so forever. A study in the April Journal of Urology found that those older than 75 with PSA levels less than 3 nanograms per milliliter are unlikely to develop aggressive prostate cancer that makes a dent in their lifespan. Those whose PSA levels exceed this mark had an escalating probability of dying from this disease.
"We need to identify where we should best focus our health care dollars by concentrating on patients who can actually benefit from PSA testing," said Edward Schaeffer, MD, lead author and assistant professor of urology at Johns Hopkins University School of Medicine in Baltimore. "These findings give a very strong suggestion of when we can start to counsel patients on when to stop testing."
U.S. Preventive Services Task Force guidelines issued in August 2008 say evidence is insufficient to recommend for or against prostate cancer screening in those younger than 75. For those older, the evidence is more clear, and this should not be done for this age group.