April 27, 2009 -- A new recommendation that men consider prostate-specific antigen (PSA) testing a decade earlier than is now the norm is being widely criticized by some of the nation's top prostate cancer experts.
The revised guidelines for men with an average risk of prostate cancer, made public today by the American Urological Association (AUA), call for baseline PSA blood testing to be offered starting at age 40, with the frequency of future testing to be determined on an individual basis.
The guidelines replace the group's previous call for annual PSA testing beginning at age 50.
Urologist Peter Carroll, MD, who chaired the AUA committee that came up with the new guidelines, says the change reflects the recognition that an abnormal PSA at a young age is strongly predictive of future prostate cancer risk.
"Prostate cancer testing is an individual decision that patients of any age should make in conjunction with their physicians and urologists," he says. "There is no single standard that applies to all men."
But American Cancer Society Chief Medical Officer Otis Brawley, MD, tells WebMD that the call for a baseline PSA will likely lead to more screening, not less, and more overtreatment of men who will not benefit.
The American Cancer Society no longer recommends routine PSA screening for all men. Instead, its guidelines call for doctors and patients to weigh the potential benefits and risks of screening before deciding on a course of action.
Brawley says none of the reliable studies examining PSA testing -- including two widely publicized trials reported last month -- has shown routine screening to positively affect death rates from prostate cancer.
"This [new recommendation] implies that screening for prostate cancer is more beneficial than it has been proven to be," Brawley says.
National Cancer Institute scientist Barnett Kramer, MD, MPH, was also critical of the call for earlier PSA screening, telling WebMD that the recommendation appears to ignore the latest and best research on the issue.
He says earlier, less reliable studies presented an overly positive view of the benefits of screening.
"These early studies led to a pseudo epidemic of prostate cancer and a lot of needless treatment," he says.
New Guidelines Address Concerns of Overtreatment
Carroll counters that earlier baseline PSA testing should lead to less screening because most patients will not need annual follow-up testing.
Other changes in the AUA guidelines reflect efforts to address the issue of overdetection and overtreatment, he says.
These changes include:
- The group no longer recommends a single PSA value at which a biopsy is recommended. Instead, predictors of risk, including family history, patient age, and ethnicity, should be considered in addition to PSA and physical exam results, Carroll says.
- For the first time, the guidelines clearly state that going without treatment is an acceptable option for patients with a positive prognosis. The strategy involves close monitoring, with treatment reserved for patients who show evidence of cancer progression.
Now known as "active surveillance," the approach has long been popular in Europe but has not been widely embraced in the U.S.
Carroll is a prostate cancer researcher at the University of California, San Francisco. "In this country, the detection and treatment of prostate cancer have been tightly linked," he says. "When we stop linking them, I believe that many of the objections to PSA testing will fall by the wayside."
Urologist Ira Sharlip, MD, who is also with the University of California, San Francisco, tells WebMD that he is comfortable recommending active surveillance to his patients who have a low risk for progression. His patients who opt for no treatment receive digital rectal exams and PSA blood tests every three months, with repeat biopsies performed every year or two.
"I personally think the limited information we have on active surveillance suggests that it is safe, but this has not been proven," he says.
One thing everyone who spoke to WebMD agreed on is that men facing decisions about PSA screening need to become educated about the issue.
Kramer recommends visiting the web sites of the National Cancer Institute and the U.S. Preventive Services Task Force.