New prostate cancer screening guidance statement

"Screening for Prostate Cancer: A Guidance Statement from the American College of Physicians" appears in the April 9 issue of Annals of Internal Medicine, published by ACP.

"Before PSA testing, doctors and patients should discuss the potential benefits and harms of screening and the patient's individual risk of prostate cancer, general health, and preferences for testing and evaluation," said David L. Bronson, MD, FACP, president, ACP. "Only men between the ages of 50 and 69 who express a clear preference for screening should have the PSA test. For most of these men, the harms will outweigh the benefits."

The guidance statement includes talking points for physicians to help them explain the benefits and harms of prostate cancer screening and treatment.

"A small number of prostate cancers are serious and can cause death," said Amir Qaseem, MD, PhD, MHA, FACP, Director, Clinical Policy, ACP. "However, the vast majority of prostate cancers are slow-growing and do not cause death. It is important to balance the small benefits from screening with harms such as the possibility of incontinence, erectile dysfunction, and other side effects that result from certain forms of aggressive treatment."

There are substantial harms associated with prostate cancer screening and treatment, including:

• Problems interpreting test results. The PSA test result may be high because of an enlarged prostate but not because of cancer. Or, it may be low even though cancer is present.
• If a prostate biopsy is needed, it is not free from risk. The biopsy involves multiple needles being inserted into the prostate under local anesthesia, and there is a small risk of infection or significant bleeding as well as risk of hospitalization.
• If cancer is diagnosed, it will often be treated with surgery or radiation, which carry risks, including a small risk of death with surgery, loss of sexual function (approximately 37 percent higher risk), and loss of control of urination (approximately 11 percent higher risk) compared to no surgery.

ACP recommends against PSA testing in average-risk men younger than 50, in men older than 69, or in men who have a life expectancy of less than 10 to 15 years because the harms of prostate cancer screening outweigh the benefits. For men younger than 50, the harms such as erectile dysfunction and urinary incontinence may carry even more weight relative to any potential benefit.

"Studies are ongoing, so we can expect to learn more about the benefits and harms of screening, and recommendations may change over time," said Dr. Bronson. "Men can also change their minds at any time by asking for screening that they have previously declined or discontinuing screening that they have previously requested."

ACP developed the guidance statement by assessing current prostate cancer screening guidelines developed by other organizations. ACP believes that it is more valuable to provide clinicians with a rigorous review of available guidelines rather than develop a new guideline on the same topic, when multiple guidelines are available on a topic, or when existing guidelines conflict.