Council weighs prostate cancer screening

Without more conclusive data, an AMA council recommends against population-based programs.

By Stephanie Stapleton, amednews staff. June 19, 2000.

To screen or not to screen?

That is the question explored by the AMA's Council on Scientific Affairs regarding the costs and benefits of population-based screening for prostate cancer. The council's report was scheduled for consideration by the House of Delegates during the AMA's Annual Meeting this month.

"We feel that the option of screening should be handled at the level of the physician-patient relationship," said Myron Genel, MD, CSA chair and an assistant dean at Yale University School of Medicine, New Haven, Conn. "There are not enough epidemiological or controlled data to determine a true cost effectiveness of screening. ... It doesn't warrant a mass screening recommendation."

Although Dr. Genel said the CSA findings are designed to offer a "state-of-the-art assessment," the report does not justify proposals for a federal mandate encouraging screenings or offering Medicare coverage. It could, however, be the basis for increased federal research funding that would provide a more definitive fact base.

Prostate cancer is the most common form of cancer and the second leading cause of cancer deaths among men. Still, because it strikes primarily older men, it ranks only 21st among the causes of years of life lost. And the level of threat it poses is not always clear-cut, according to the report.

A 50-year-old man with a 25-year life expectancy has a 30% chance of having a microscopic cancer detected and a 10% chance of clinically evident disease. However, the risk of dying from prostate cancer is 3%.

"The disparity between the 30% prevalence ... and the 3% lifetime risk of death shows the difficulty in distinguishing cancer that is destined to cause illness and death from indolent disease," notes the report. And, though early detection has been shown to improve survival rates, the path of intervention and treatment can bring with it serious and uncomfortable conditions.

The council does recommend that:

Men who would be candidates for active treatment should receive information regarding risks and the potential benefits and harms of screening.
Elected screening should include both prostate-specific antigen testing and digital rectal examination.
Men most likely to benefit include those 50 or older with a life expectancy of at least 10 years.

Currently, the American Cancer Society, the American Urological Assn. and the American College of Radiology recommend that both PSA and DRE should be offered annually, beginning at age 50, to men who have at least a 10-year life expectancy and to younger men who are at high risk.

From the perspective of the U.S. Preventive Services Task Force, however, routine screening with DRE, PSA or transrectal ultrasound is not recommended.

The American College of Preventive Medicine recommends against routine screening with PSA and DRE, but suggests that men older than 50 should be informed about the potential benefits and harms of screening and be allowed to make their own choices. Meanwhile, the American College of Physicians suggests that rather than routinely screening all men, physicians should describe potential benefits and known harms of screening, diagnosis and treatment.

In other action

Among other public health issues on tap during the AMA's Annual Meeting in Chicago is a CSA report examining physicians' role in organ donation.

Meanwhile, a range of policy proposals was also slated for consideration. The house could vote on whether the AMA should endorse firearm education for young people as well as press for stricter enforcement of gun control laws and safety features.

Debate is also expected regarding:

Homosexual conversion therapy.
Drug formularies and the oversight of pharmaceutical benefit managers and third-party payers.
Funding for clinical and translational research as well as the training of new investigators.
Issues related to vaccines, including whether pricing influences labeling recommendations.