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New Prostate Cancer Screening Guidelines Puts Patient Choice First

The U.S. Preventive Services Task Force (USPSTF) published a new recommendation that men ages 55 to 69 should decide for themselves whether to undergo a prostate-specific antigen (PSA) test after discussing the potential benefits and harms with their doctor.

This test measures the production of a protein produced in your blood by the prostate, a small walnut-shaped gland in the abdomen that produces seminal fluid as part of the reproductive system. Cancerous prostate tissue typically produces higher levels of PSA.

The new recommendation is in step with those issued by the American Urological Association and the American Cancer Society.

Previously, the task force had recommended that no men receive a PSA cancer screening because the disease is most often very slow growing and the side effects of premature treatment can be significant, such as erectile dysfunction and urinary incontinence. All three groups continue to recommend that men over 70 not be tested for PSA for these reasons.

The USPSTF data showed that out of 1,000 men who receive a PSA screening:

  • 240 men will have an elevated PSA score.
  •  Of those 240 men, only 100 will have a cancer diagnosis.
  • Of those 100 prostate cancer patients, 80 will undergo surgery or radiation either immediately or after a period of active surveillance.
  • Of the 80 men who receive treatment, 50 will suffer erectile dysfunction and 15 will suffer urinary incontinence.

The task force advises patients to talk with their physicians about their personal situation regarding health, family history, and risk factors. The group also advises men to balance the benefits of treatment against the potential negatives, which include false-positive results that require additional testing and possible prostate biopsy, overdiagnosis and overtreatment, and treatment complications.

Fox Chase Cancer Center urologic oncologist Marc C. Smaldone, MD, MSHP, FACS, reflects on the new recommendation and what it means for patients.

Q: Why is it important for men to know about the task force’s recommendation?

A: The recommendation gives primary care providers and their patients more flexibility in deciding about screening and treatment options.

The PSA test is just one of the ways to detect cancer before or after treatment, but it may show false-positive results that can lead to overdiagnosis and overtreatment. Measuring a diagnosed cancer’s risk is more effective using the Gleason score, which summarizes the analysis of biopsied prostate tissue samples. MRI scanning is becoming increasingly common for detection and tracking. Even a simple digital rectal exam is effective for finding some prostate cancer tumors, regardless of what a PSA test shows.

Q: Who qualifies for active surveillance?

A: If you have low risk disease (Gleason 6, low volume, PSA <10), which roughly 70 to 80 men are diagnosed with, your cancer can be very safely managed with active surveillance for at least an initial period so that you don’t have to immediately begin treatment.

In my practice, about 90 to 95 percent of patients with low risk disease start on active surveillance. For them, we use risk assessment tools such as repeat biopsies, MRIs, and genomic testing to identify those who have more aggressive disease that was missed or under sampled in their initial biopsy.

About 30 to 40 percent of patients who meet the criteria for active surveillance will ultimately undergo some type of intervention, but it may not come for some time. The longer we can safely delay treatment, the longer we can avoid some of the potential side effects.

The key point with active surveillance is that it is not a decision to decline treatment, but rather it’s a decision to delay treatment until there are indications that treatment has become necessary.

Q: Are there concerns that some men will hear the recommendation and decide against PSA screening?

A: When someone is faced with the decision whether to undergo PSA screening,, they will often say no due to a fear of requiring cancer treatment, That’s not really true. Screening is important to detect clinically significant cancers that post a threat, but patients need to understand that a diagnosis of low risk (or clinically insignificant disease) does not require quality-of-life-altering treatment.

Q: Does the recommendation have any other impacts?

A: If a patient decides after talking with a doctor that he wants to undergo PSA testing, the task force’s recommendation implies insurers will cover its cost. The recommendation comes with a grade C rating, a guideline most insurers will follow.

To find out more about prostate cancer at Fox Chase Cancer Center.