From Medscape Medical News
Nick Mulcahy
March 3, 2010 — For the first time since 2001, the American Cancer Society (ACS) has updated its prostate cancer screening guideline.
There are also several new recommendations for men who choose to be tested.
Prostate-specific antigen (PSA) testing is now recommended with or without the digital rectal exam (DRE). "There is little evidence that the digital rectal exam adds significant benefit to the PSA test, except, perhaps, when the PSA is in the borderline range," he said.
The ACS continues to recommend that the PSA value of 4.0 ng/mL be used as a "reasonable threshold" to trigger further evaluation, said Dr. Wolf.
However, there is a new recommendation for men with PSA values between 2.5 and 4.0 ng/mL.
"Recognizing that approximately 25% of men with PSA levels between 2.5 and 4.0 ng/mL harbor prostate cancer, we have added a recommendation that physicians consider an individualized risk assessment for men with PSA values in this indeterminate range," said Dr. Wolf.
An individual assessment should take into account non-PSA risk factors, such as race, family history, results of previous biopsies, and DRE results, he said
ACS also now recommends that the PSA testing interval be reduced to every other year for men whose PSA level is under 2.5 ng/mL. "Such a reduction in testing frequency will lead to significantly reduced false positives, unnecessary biopsies, and overdiagnosis, with only a negligible increase in missed cancers," explained Dr. Wolf.
The American Urological Association (AUA) differs with the ACS on PSA values. "The AUA feels there is no single PSA standard that applies to all men, nor should there be," they write in a press release issued soon after the guideline was made public this week.
"Although prostate cancer risk correlates with serum PSA, there is no PSA value below which a man may be reassured that he does not have biopsy-detectable prostate cancer," the AUA press release adds. The AUA also advocates for a baseline PSA test at the age of 40, and subsequent rescreening that evaluates, among other risk factors, free and total PSA, PSA velocity, and PSA density.
Informed Decision-Making: By Age and Core Elements
At the age of 50, men at average risk for prostate cancer should start receiving facts about prostate cancer and screening, states the new ACS guideline. Men at higher risk, including African American men and men with a first-degree relative (father or brother) diagnosed with prostate cancer before age 65, should receive this information beginning at age 45.
Men at "appreciably higher risk" (multiple family members diagnosed with prostate cancer before age 65) should receive information beginning at age 40.
The "core elements" of the information to be provided to men to assist with their prostate cancer screening decision include the following:
Screening with the PSA blood test detects cancer at an earlier stage than if no screening is performed.
Prostate cancer screening might be associated with a reduction in the risk of dying from prostate cancer; however, evidence is conflicting.
For men whose prostate cancer is detected by screening, it is not currently possible to predict which men are likely to benefit from treatment.
Treatment for prostate cancer can lead to urinary, bowel, sexual, and other health problems that can be significant or minimal, permanent or temporary.
The PSA and DRE can produce false-positive or false-negative results.
Abnormal results from screening with PSA and DRE require prostate biopsies, which can be painful and lead to complications like infection or bleeding.
Not all men whose prostate cancer is detected through screening require immediate treatment. Some require periodic blood tests and prostate biopsies to determine the need for future treatment.
Dr. Hoffman reports receiving partial salary support from the nonprofit Foundation for Informed Medical Decision Making to help develop a prostate cancer screening decision aid.
CA Cancer J Clin. Published online March 3, 2010.
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