Prostate Cancer Screening
Looser Guidelines Issued on Prostate Screening
Published: May 3, 2013
In a major shift, the American Urological Association has pulled back its strong support of prostate cancer screening, saying that the testing should be considered primarily by men aged 55 to 69.
The association had staunchly defended the benefits of screening men with the prostate test, even after a government advisory committee, the United States Preventive Services Task Force, said in 2011 that healthy men should not be screened because far more men would be harmed by unnecessary prostate cancer treatments than would be saved from death.
But in new guidelines issued Friday, the urology association says that routine screening is no longer recommended for men 40 to 54 years old who are at average risk of getting prostate cancer. Screening is also not recommended for men 70 and older.
The guidelines say men 55 to 69 should discuss the benefits and harms of screening with their doctors. And if they do choose screening, an interval of two years rather than annually would be better.
“It’s time to reflect on how we screen men for prostate cancer and take a more selective approach in order to maximize benefit and minimize harms,” Dr. H. Ballentine Carter, a professor of urology and oncology at Johns Hopkins University and chairman of the committee that drafted the guidelines, said in a statement.
The urology association’s previous recommendation, issued in 2009, was that blood testing for P.S.A., which stands for prostate-specific antigen, should be offered to men starting at age 40. Millions of men now get the P.S.A. test, many as part of their annual checkup.
When the government advisory task force recommended against screening, urologists, who treat many men with prostate cancer, expressed outrage, with one saying the policy was “flawed, dangerous and catastrophic for men.”
But some prostate cancer experts say the association risked losing credibility had it stuck to its recommendations for widespread screening. The new guidelines, they say, could preserve P.S.A. screening by recommending more moderate use.
The association “is not dismissing the P.S.A. test as the task force has done,” said Dr. Philip W. Kantoff, a prostate cancer specialist at the Dana-Farber Cancer Institute in Boston who was a member of the guidelines committee. “There should be a more reasonable approach to the use of P.S.A.”
Dr. David F. Penson, chairman of the urology association’s health policy council, said the new guidelines reflected the results of two recent clinical trials. “We just put our recommendations in line with the evidence,” he said.
The problem with screening is that levels of P.S.A. can be elevated for reasons having nothing to do with prostate cancer. That leads many men to have unnecessary biopsies, which can cause pain and infections. And biopsies find many cancers that would be so slow-growing that they would never harm the man. Because it is difficult to distinguish the dangerous from the nonaggressive tumors, however, most men undergo surgery or radiation treatments and then suffer from side effects like incontinence and erectile dysfunction.
In its guidelines on Friday, the association said that for men 55 to 69, screening would prevent one prostate cancer death for every 1,000 men screened over a decade.
The guidelines say that some men at higher-than-average risk of getting prostate cancer, such as those with a family history or who are African-Americans, could discuss the benefits and harms of starting screening at an age earlier than 55.
Some experts skeptical of screening have noted that the advent of P.S.A. testing led to a big jump in the number of diagnoses of prostate cancer, increasing the business of urologists. The P.S.A. test underpins a prostate cancer industry, consisting of laboratories that do biopsies, manufacturers of surgical robots and radiation equipment, even suppliers of adult diapers.
Dr. Otis W. Brawley, the chief medical officer of the American Cancer Society, has been a critic of mass screening campaigns, such as those held at shopping malls. “There has been a lot of money made by hospitals and clinics doing these mass screenings,” he said, referring to the treatment after cancer is found.
Dr. Brawley said the new urological association guidelines were “wonderful” if they were put into effect and would bring the association closer to the position of the American Cancer Society.