Prostate cancer screening guidelines updated

The American Cancer Society has updated its screening guidelines for prostate cancer, emphasizing that doctors educate patients about the potential risks and benefits of screening.

The updated guidelines, published online March 3 in CA: A Cancer Journal for Clinicians, keep the society's core recommendations on what age to begin discussions. The main difference from the last ACS guidelines issued in 2001 is the emphasis on informing patients about screening uncertainties and involving patients more in the decision-making process (link).

"With all the evidence we've got, it's increasingly clear that the benefits are uncertain for prostate cancer screening," said Andrew Wolf, MD, lead author of the ACS guidelines and associate professor of medicine at the University of Virginia School of Medicine. "We felt it was time to really emphasize the informed and shared-decision making [approach]."

The cancer society continues to recommend that physicians begin discussing prostate cancer screening with male patients when they are 50 years old. Screening discussions should begin at age 45 for those considered at higher risk for prostate cancer, including blacks and men with a father or brother diagnosed with the disease before age 65.

Men with multiple family members diagnosed with the disease before age 65 should receive screening information at age 40. Patients with less than a 10-year life expectancy, due to age or health status, should not be screened.

Urologist Brantley Thrasher, MD, said the revised guidelines won't likely change how he talks about screening with patients. He said doctors need to ensure adequate dialogue with patients to help them in the decision-making process.

"It basically is echoing what many of us have said for quite some time -- that you need to make sure you're discussing the pros and cons of this with your patients," said Dr. Thrasher, a professor and chair of urology at the University of Kansas Medical Center.

A leading cause of cancer

Prostate cancer is the most commonly diagnosed cancer among U.S. men and remains the second leading cause of cancer death in males, following lung cancer, according to the ACS. In 2009, about 192,000 men were diagnosed with prostate cancer, with 27,000 expected to die from the disease.

The revised ACS guidelines intend to help physicians detect who is most at risk of dying and who could survive without potentially harmful treatment. To do this, the society updated clinical recommendations on screening intervals.

The ACS recommends men whose PSA level is 2.5 ng/mL or higher be screened annually. For men whose PSA levels are between 2.5 ng/mL and 4.0 ng/mL, physicians are encouraged to consider individual risk factors, including age, ethnicity and family history.

Men at an average risk of developing prostate cancer and who have PSA levels of 4.0 ng/mL or higher should be referred for further evaluation or biopsy.

The guidelines also call for talking to patients about the benefits and harms associated with screening, including false test results and side effects of treatment. The ACS suggests that doctors enhance their discussions with written information or videos with balanced, up-to-date information.

If a patient still can't decide what to do, the screening decision should be left to the physician. That differs from previous ACS guidelines, which said men should be tested if they can't make a decision.

The revised guidelines say men who have had a PSA test do not need a digital rectal exam, because the exam has not clearly shown a benefit.

Physician participation in community-based prostate screening programs, such as those held at health fairs, is discouraged unless the programs adequately provide an informed decision-making process with the patient and appropriate follow-up care. "We're not recommending that all these [community] programs end," Dr. Wolf said. "We're just saying they need to be held to the same standards that physicians are held to."