PSA screening not advised for most men 54 and younger

The latest prostate cancer screening guideline could help clarify primary care physicians' uncertainty about who should be tested, said urological surgeon David F. Penson, MD, MPH.

The new guidance, which was issued May 3 by the American Urological Assn., recommends against prostate-specific antigen screening for men younger than age 40 and does not recommend routine screening in average-risk men ages 40 to 54. Shared decision-making is strongly encouraged for men 55 to 69 who are considering PSA screening.

The guidance differs from the AUA's 2009 recommendation, which encouraged physicians to offer a PSA test and a digital rectal exam to asymptomatic men 40 and older who wanted to be screened and who have a life expectancy of more than 10 years.

“New evidence since 2009 … led us to a somewhat different conclusion,” said Dr. Penson, chair of the AUA's Health Policy Council and one of 12 experts who helped develop the latest recommendations.

The direction is more in line with guidelines by other medical organizations that focus on educating patients about the benefits and risks of PSA testing. The message for primary care physicians is that men ultimately should be allowed to make their own decisions.

“Look at [guidelines issued by the] American Cancer Society, National Comprehensive Cancer Network and the American College of Physicians — they all say it,” said Dr. Penson, professor of urology and director of the Vanderbilt Center for Surgical Quality and Outcomes Research at Vanderbilt University Medical Center in Tennessee.

He said if a man still wants a PSA test after being educated on the risks and benefits, the physician should order it. “If they don't want it, put it in their chart and you're done.”

A challenge for primary care physicians, however, is finding sufficient time during office visits to discuss prostate cancer screening and answer patients' questions about the procedure, said medical oncologist Tomasz Beer, MD. It's easy for experts to recommend that primary care doctors educate patients about PSA screening, but it's a difficult topic to explain in a short period of time, said Dr. Beer, deputy director of the Oregon Health and Science University Knight Cancer Institute.

To make such discussions more manageable, Dr. Penson encourages physicians to use online medical decision-making tools that are tailored for prostate cancer screening. For instance, the Informed Medical Decisions Foundation offers a comprehensive online decision-making aid for men considering whether to have a PSA test.

When the information is explained clearly, “patients are smart enough to decide what's important for them,” Dr. Penson said.

Prostate cancer is the second-most commonly diagnosed cancer among U.S. men and remains the second-leading cause of cancer death in men after lung cancer, according to the American Cancer Society.

Research influences change

Work on the AUA's new guideline began in the fall of 2011, before the U.S. Preventive Services Task Force issued its May 2012 recommendation urging physicians to stop using the PSA test to screen asymptomatic men for cancer.

In developing the guidance, the panel, which included experts in epidemiology, medical oncology, primary care and urology, reviewed more than 300 studies on prostate cancer detection and screening that were published between 1995 and 2013.

Among the data assessed for the updated guidance were findings from a European study showing that PSA screening every two to seven years was associated with a 20% relative reduction in risk of prostate cancer death in men age 55 to 69. A large U.S. study, on the other hand, found that screening had no effect on death related to the disease.

Particular attention was paid to screening harms. About a third of men who undergo a prostate biopsy experience mild to severe symptoms such as bleeding, fever, infection and problems urinating, the AUA said.

For men who choose to get the test, routine screening every two years or less frequently is preferred over annual screening, the guideline states. The AUA does not recommend routine PSA screening in men older than 70 or in men with less than a 10- to 15-year life expectancy.

The guidance is not for men at high risk of developing prostate cancer, which includes blacks and those with a family history of the disease, the AUA said.

“The best available evidence suggests that following these guidelines will lead to an improved benefit-to-harm ratio,” said urologist H. Ballentine Carter, MD, chair of the AUA panel that developed the guideline.