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A Yellow Light, but Little Guidance, on PSA Tests

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May 8, 2018 -- Should you get a PSA test for prostate cancer? In 2012, an influential panel of doctors that makes recommendations on preventive care answered that question with a firm ‘No.’ 

That’s because studies showed that the harms of these blood tests -- including misleading results, infections, anxiety, and aggressive treatment of cancers that may never have harmed a man if left undiscovered -- seemed to outweigh any potential benefits.

Today, though, that same group, the U.S. Preventive Services Task Force, has officially softened its stance. It says prostate cancer screening tests make sense for some men between the ages of 55 and 69, including those with a higher-than-average risk because of a family history of prostate or related cancers or because they are African-American.

Two studies recently presented at the European Association of Urology Congress found that cases of aggressive prostate cancer have increased in the U.S. since the 2012 recommendation against PSA testing was published.

The task force says these men should undergo PSA testing only after having a detailed discussion about the pros and cons with their doctor.

The PSA is a blood test that measures a protein that’s made by the prostate, a small gland that sits just beneath the bladder and makes seminal fluid.  Prostate cancers make more of this protein.

The trouble is that many men never have that important talk, which is part of a process known in medicine as shared decision making. 

A 2018 study by the American Cancer Society found only about 17% of men who’d had a recent PSA test had done so after a complete discussion with their doctor.  The same study found that about 38% of men got no information from their doctor before having the test.  When doctors did talk with patients, they often spoke in glowing terms, touting the test’s benefits but not its risks.

“I don’t think most primary care clinicians have the data at their hand to be able to sit down and counsel a man about how many men will have to be overdiagnosed with prostate cancer to just prevent one death,” says Therese Bevers, MD, medical director of the Cancer Prevention Center at M.D. Anderson Cancer Center in Houston.

Overtreatment’s Dangers

Overdiagnosis means the test and a follow-up biopsy will find a non-aggressive cancer, one that probably wouldn’t grow or spread.  Overdiagnosis can lead to overtreatment, which can, in turn, can cause life-altering complications like incontinence and impotence.

The task force has estimated that for every 1,000 men who get a PSA test, between 20 to 50 men will be overdiagnosed for every one to two deaths that are prevented. 

“It’s really difficult for both patients and providers to understand the evidence,” says Ruth Etzioni, PhD, of the Fred Hutchinson Cancer Research Center, who studies the pros and cons of PSA testing.

Etzioni says she’s glad that the task force has lifted its blanket determination that PSA testing is unwarranted. But she wishes the panel had offered men and their doctors more information about implementing the guidelines to help them make what can be a difficult decision.

“It’s a little bit kicking the can down the road to just say, ‘You guys figure it out. We can’t tell you whether to do it or not,'” Etzioni says.

The task force is releasing a graphic and a patient-friendly explanation of their new recommendation.

'Doctor's Don't Really Get Paid to Talk to Patients'

Still, some experts say these materials won’t be enough.

“I don’t think the resources are out there, which is really unfortunate,” says Otis Brawley, MD, chief medical and scientific officer at the American Cancer Society.

Brawley, too, says he is glad to see that the task force now advises middle-aged men to make a decision about PSA testing with their doctors. It brings their recommendations in line with both the American Urological Association and the American Cancer Society. 

But he also says he isn’t hopeful that more patients would get a PSA test with a full understanding of its risks.

“Doctors don’t really get paid to talk to patients. If you’re in a primary care setting, as soon as you go into the room, the clock starts. You’ve got to deal with all the issues of that patient and get in and out of the room in 15 minutes,” Brawley says.

“There are so many things on a family practice doc’s plate that they really don’t take the time to do informed decision-making,” he says.

A Very Rare Diagnosis

So what should you know when considering PSA testing?

“The first thing they should know, if they’re in their 50s, is that it’s a very rare diagnosis,” Etzioni says.

Just 2% of men, or 1 in 50, will be diagnosed with prostate cancer in their 50s, according to the National Cancer Institute. About 6% of men, or 1 in 16, are diagnosed in their 60s.

The risks of deadly prostate cancers are higher for men who have parents, brothers, or sisters who have been diagnosed with certain kinds of aggressive cancers called adenocarcinomas.  These include cancers of the prostate, breast (male or female), ovary, or pancreas, especially if that relative got their cancer at a young age and it spread quickly.

For that reason, the task force recommends that men with this kind of family history talk to their doctor about PSA testing.

African-Americans Face Higher Risks

Prostate cancer is more common in African-American men. It’s also more deadly. For those reasons, the task force says African-American men may benefit from regular PSA testing starting at age 55, after talking with their doctors.

The American Cancer Society and the American Urological Association say African American may consider screening even earlier--as young as age 45-- after consultation with their doctors.

While the potential benefits of testing are small, they’re most significant for men who are younger and otherwise healthy.

Doctors shouldn’t test men who are already managing many other health conditions such as heart disease, obesity, or diabetes, says H. Ballentine Carter, MD, a surgeon and prostate cancer researcher at Johns Hopkins University.  “They have bigger fish to fry,” in a sense, Carter says. 

Prostate cancer wouldn’t be their most pressing health concern, or the one that would be the most likely to shorten their life or their quality of life.

“We all have to prioritize what we need to do to improve our health.  This may not be at the top of the list,” Etzioni says.

You should also think about how willing you might be to go through treatment.  If you don't want to risk complications like bowel problems, erectile dysfunction, or incontinence, the task force says you shouldn’t get a PSA test.

Likewise, they say most men age 70 or older shouldn’t be tested since the risks still outweigh any potential benefits for them.

‘Watchful Waiting’ Preferred

Finally, while overdiagnosis is still a problem in prostate cancer, overtreatment has become less likely because doctors have become more comfortable with a treatment strategy called watchful waiting. That means you see your doctor regularly to keep tabs on the cancer but don’t treat it.

“What has now happened is that in the last 5 to 7 years, we’ve gotten better at identifying the men who don’t need treatment vs. the men who do need treatment,” Brawley says. “Most men who will be diagnosed with prostate cancer will be watched instead of treated. That’s a big change.”

Even if you decide to skip PSA testing, the Prostate Cancer Foundation says you should see a doctor if you have any symptoms of prostate problems, which may include:

  • A need to pee often, especially at night
  • Trouble starting or stopping urine
  • Weak, dribbling, or interrupted stream of urine
  • Pain or burning when you pee
  • Trouble getting an erection
  • A decrease in semen
  • Pain when you ejaculate
  • Blood in your urine or semen
  • Pressure or pain in your rectum
  • Pain or stiffness in your lower back, hips, pelvis, or thighs
WebMD Article Reviewed by Arefa Cassoobhoy, MD, MPH on May 08, 2018

Sources

Therese Bevers, MD, professor, Clinical Cancer Prevention, M.D. Anderson Cancer Center, Houston.

Ruth Etzioni, PhD, biostatistician, Fred Hutchinson Cancer Research Center, Seattle.

Otis Brawley, MD, chief medical and scientific officer, American Cancer Society, Atlanta.

H. Ballentine Carter, MD, surgeon and prostate cancer researcher, Johns Hopkins University, Baltimore.

Annals of Family Medicine, March/April 2018.

Journal of the American Medical Association, May 8, 2018.

CDC: "Prostate Cancer Risk by Age."

European Association of Urology 2018 Congress, Copenhagen, Denmark

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