Am Fam Physician. 2002 May 1;65(9):1752-1757.
Although the prostate-specific antigen (PSA) test has been in widespread use as a cancer screening tool for well over a decade, early detection and treatment remain clouded by unresolved questions. The argument over the value of PSA testing in asymptomatic men has been highlighted on several occasions in American Family Physician.
Updated prostate cancer screening guidelines1 from the American Cancer Society are as follows: (1) The PSA screening test and a digital rectal examination should be offered annually to men, beginning at age 50, who have a life expectancy of at least 10 years. (2) Men at high risk should undergo initial screening at 45 years. (3) Before screening tests are conducted, patients should be given the opportunity to learn about the benefits and limitations of testing for early prostate cancer detection and its subsequent treatment.
The American Academy of Family Physicians supports the need to review with patients the appropriateness of screening for prostate cancer, recommending that men be made aware of the uncertain benefits of and the potential risks associated with screening.2 The U.S. Preventive Services Task Force3 does not recommend the use of PSA screening until available evidence indicates that the test saves lives.
Although the recommendations have not been changed, evidence now demonstrates that mortality rates and the incidence of advanced metastatic disease have substantially decreased since the onset of PSA-based prostate cancer screening. Whether this reduction is the result of PSA screening and the subsequent treatment of early disease can be argued; however, the recently identified decline in prostate cancer mortality in white men under 85 years of age to levels below those of the pre-PSA era, combined with a reduction in the incidence of distant disease, is highly suggestive of a positive effect of PSA testing.4,5 Population-based studies6,7 demonstrate a decline in mortality related to prostate cancer—apparently associated with PSA testing. A more definitive prospective randomized trial is in progress,8 but the results will not be available for several more years. Meanwhile, the use of PSA screening continues to expand. As physicians, what are we to do?
We daily offer patients many preventive health interventions; for some of these interventions, effectiveness and mortality reduction are evidence-based (e.g., mammography) and, for other interventions, they are self-evident but not “proved” through randomized, controlled trials (e.g., Papanicolaou smears). Where in our busy schedule does the PSA screening test fit? How much discussion and education are appropriate? Patients no longer accept health care being dictated to them on a “doctor knows best” basis, but they still depend on us for guidance and direction. In light of the current state of the science related to the PSA test, our responsibility is to make our patients aware that the PSA assay is available and to help them understand the associated implications.
Patients should be helped to understand that the PSA assay is not specific for cancer, that some benign conditions can result in an “abnormal” level, and that some cancers may exist despite a PSA value within the normal range. The conversation should also include the “next steps” that would be necessary if the test result is abnormal, including referral for additional tests (e.g., ultrasonography, needle biopsy).
Discussing selection of therapy and choosing among various options, including watchful waiting, can be specifically framed only in the context of a known histologic diagnosis and tumor grade. Patients should, however, have a general understanding that any benefit associated with testing and a reduced risk of mortality from prostate cancer can be obtained only by use of treatment interventions that also have risks.
We should advise our asymptomatic patients when routine consecutive testing most likely will be of little benefit because of advanced age or the presence of serious co-morbid conditions. We should advise patients of the need for vigilance when they are at increased risk (because of race or a family history of cancer) of developing or dying of prostate cancer. They should be aware that the PSA test can detect prostate cancer at an earlier and potentially more treatable stage and may improve their chance for survival. This is the essence of an informed decision.
It has been suggested that, given the limited time available to discuss preventive issues, we should focus our efforts on interventions with known efficacy. A decision on our part not to present patients with the option of PSA testing is tantamount to placing patients who may have asymptomatic prostate cancer into treatment with watchful waiting without their consent. However, this is not an informed decision, and the patient may not be pleased with the outcome.
While counseling is time-consuming, it seems that the best option is to provide patients with the most current information and allow them to select the best course of action. We are much more likely to have satisfied patients in the future if we make the necessary investment of time to allow them to participate in the decision-making process today.
Lewis E. Foxhall, M.D., is associate professor of clinical cancer prevention and associate vice president for health policy at the University of Texas M.D. Anderson Cancer Center, Houston.
Andrew C. von Eschenbach, M.D., is professor of urology, special assistant for external affairs, and director of the Genitourinary Cancer Center at the University of Texas M.D. Anderson Cancer Center.
Address correspondence to Lewis E. Foxhall, M.D., Texas Medical Center, 1515 Holcombe Blvd., Houston TX 77030.
1. Smith RA, von Eschenbach AC, Wender R, Levin B, Byers T, Rothenberger, et al. American Cancer Society guidelines for the early detection of cancer. CA Cancer J Clin. 2001;51:41–5.
2. Periodic health examinations. Summary of AAFP policy recommendations and age charts. Revision 4.0, July 2000. Retrieved December 2001, from: www.aafp.org/exam/index.html
3. U.S. Dept. of Health and Human Services, Office of Public Health Science, Office of Disease Prevention and Health Promotion. Guide to clinical preventive services: report of the U.S. Preventive Services Task Force. 2d ed. Baltimore: Williams & Wilkins, 1996:119–34.
4. Ries L. Seer cancer statistics review, 1973–1997. Bethesda, Md.: National Cancer Institute, 2000; NIH publication no. 00-2789.
5. Tarone RE, Chu KC, Brawley OW. Implications of stage-specific survival rates in assessing recent declines in prostate cancer mortality rates. Epidemiology. 2000;11:167–70.
6. Roberts RO, Bergstralh EJ, Katusic SK, Lieber MM, Jacobsen SJ. Decline in prostate cancer mortality from 1980 to 1997, and an update on incidence trends in Olmstead County, Minnesota. J Urol. 1999;161:529–33.
7. Bartsch G, et al. Decrease in prostate cancer mortality following introduction of prostate specific antigen (PSA) screening in the federal state of Tyrol, Austria. American Urological Association 95th annual meeting. Atlanta, Georgia, USA. April 29-May 4, 2000.
8. Kramer BS, Gohagen J, Porok PC, Smart C. A National Cancer Institute sponsored screening trial for prostatic, lung, colorectal, and ovarian cancers. Cancer. 1993;71(2 suppl):589–93.
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