Task force adds opinion in prostate screening debate

The preventive services panel finds inconclusive evidence to recommend testing, but encourages doctors to discuss the risk-benefit with patients.

By Susan J. Landers, amednews staff. Jan. 6, 2003.

Washington -- A federal panel's recent determination that there is no evidence that either proves or disproves the benefits of routine screening of all men for prostate cancer may actually represent a step in favor of screening.

Despite its negative ring, the Dec. 2 determination by the U.S. Preventive Services Task Force brings their recommendations more in line with those of many major medical groups, including the American Medical Association, the American Cancer Society and the American Academy of Family Physicians.

Screening positions
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For example, acknowledging that the evidence is not clear as to the benefit of screening, the AMA favors leaving the option up to physicians and their patients.

The American Cancer Society recommends that all men older than 50 be offered the screening and that men at high risk of developing prostate cancer -- those who are African-American or who have a father or brother with the disease -- be screened beginning at age 45.

In contrast, the task force had previously recommended against the use of screening, either by digital rectal examination or prostate-specific antigen testing.

"The way we at the American Cancer Society feel is that they have somewhat softened their position," said Durado Brooks, MD, MPH, director of prostate and colorectal programs.

50% to 65% of men older than 50 have been screened for prostate cancer.

Even though there are differences within the medical community on how strongly to promote the screenings, all agree that an important discussion must take place between physicians and patients concerning the benefits and risks of treatment for prostate cancer.

"Many men have the misimpression that screening for prostate cancer is like screening for breast cancer and that if you find it, in every case it is something that definitely should be treated," said Dr. Brooks.

However, treatment is not always called for.

"The challenge has really been, because prostate cancer is such a slow-growing disease and many of the cases occur in older men who have other medical problems, that not every case of prostate cancer has to be treated aggressively. Men often don't know that," said Dr. Brooks.

The nation's health system is also bearing the hundreds of millions of dollars it costs to pay for the tests, which are covered by Medicare. An estimated 50% to 65% of men older than 50 have been screened for prostate cancer, Dr. Brooks said. "Many of those tests are no doubt necessary, and men would have chosen to have them if given the information, but some of them would likely have opted not to be tested if given the option."

Harsh realities

But explaining the somewhat complex situation surrounding prostate cancer screening can take a good 10 to 20 minutes during an already jam-packed office visit, noted Daniel Van Durme, MD, a family physician in Tampa, Fla. Many physicians find it easier to postpone that discussion and instead check off a form approving a PSA test. If the test comes back abnormal, a longer discussion on the pros and cons of proceeding with treatment can then take place, said Dr. Van Durme.

Fear of medical liability may also drive physicians to prescribe the test, he said.

Treatment for prostate cancer can result in chronic urinary difficulties or erectile problems.

He relates a possible scenario that would have a patient's attorney saying: "Three years ago, doctor, you could have gotten a PSA on this patient and you didn't do it."

In an ideal world, Dr. Van Durme said, a lengthy discussion on the pros and cons of the screening would take place. "But the sad part of the reality is that we are far from an ideal world."

Prostate cancer screening is not like a test for cervical cancer, he noted, which female patients should be strongly encouraged to receive and where physicians should "quite frankly, gently twist patients' arms if they don't want to get it done and tell them, 'You should do this.' "

The reasons behind all the cautions and complexities of screening center on the complications that can result from available treatments, which include surgery and radiation.

Treatment could lead to chronic urinary difficulties or erectile problems, said Dr. Brooks. "Men really need to understand before making that testing decision what some of the potential difficulties are and whether they want to enter the diagnostic and treatment cascade associated with prostate cancer."

A new study of prostate cancer patients also shows that many men are unaware of the likelihood of a recurrence of their cancer following initial treatment. Of the 500 men surveyed, 66% believed that their prostate cancer had been cured.

However, 10-year clinical recurrence rates following radical prostatectomy and radiation therapy can exceed 30%, said Us Too! International Inc., a support and education group for men with prostate cancer based in Downers Grove, Ill.

Despite the treatment flaws, men at high risk of developing prostate cancer stand to benefit from the task force's changed stance on screening. "Physicians are largely influenced by the U.S. Preventive Services Task Force and, because their prior recommendations actually discouraged screening, many physicians don't routinely screen," said Dr. Brooks. "I think those physicians are overshooting the mark also. I think the man should be offered the option of having that screening and be informed about the potential outcomes."

ADDITIONAL INFORMATION:

Screening positions

U.S. Preventive Services Task Force

Evidence is insufficient to recommend for or against routine screening using prostate-specific antigen testing or a digital rectal examination. Although the task force found that screening does lead to early detection and some prostate cancers benefit from treatment, there is uncertainty whether potential benefits of screening justify potential harms. If physicians opt to perform screening for individual patients, they should first discuss uncertain benefits and possible harms.

American Medical Association

Launching mass prostate screening programs is premature at this time. Physicians should provide patients with information regarding the risks and benefits to make an informed decision about screening. When screening is done, it should include both a PSA blood test and DRE, and men most likely to benefit include those who have a life expectancy of at least 10 years; who are 40 or older and of African-American descent; who have an affected first-degree relative; and others who are 50 or older.

American Cancer Society

Health care professionals should offer the PSA blood test and DRE yearly, beginning at age 50, to men who have at least a 10-year life expectancy. Men at high risk, such as African-Americans and men who have a first-degree relative diagnosed with prostate cancer at an early age, should begin testing at 45.