American Cancer Society Updates Prostate Cancer Screening Guidelines
Update Reaffirms the Importance of Shared Decision-Making
ATLANTA – Newly updated prostate cancer screening guidelines from the American Cancer Society reaffirm the recommendation that men should discuss the uncertainties, risks and potential benefits of screening for prostate cancer before deciding whether to be tested. The update is the first since 2001 and was done as part of the Society’s regular guidelines update process. It included a series of systematic reviews focusing on the latest evidence related to the early detection of prostate cancer, screening test performance, harms of therapy for localized prostate cancer, and shared and informed decision making in prostate cancer screening.The guideline is published online in advance of print publication in CA: A Cancer Journal for Clinicians.
The updated guidelines include these recommendations:
“Two decades into the PSA era of prostate cancer screening, the overall value of early detection in reducing the morbidity and mortality from prostate cancer remains unclear,” said Andrew M. Wolf, M.D., Associate Professor of Medicine at the University of Virginia Health System and Chair of the Advisory Committee. “While early detection may reduce the likelihood of dying from prostate cancer, that benefit must be weighed against the serious risks associated with subsequent treatment, particularly the risk of treating men for cancers that would not have caused ill effects had they been left undetected.” The authors say in light of ongoing uncertainties, including the uncertain balance between benefits and risks, involving men in the screening decision is crucial.
“With these newly updated recommendations, the American Cancer Society places even stronger emphasis on shared decision making between clinicians and patients,” said Otis Brawley, M.D., chief medical officer of the American Cancer Society. “The decision whether to screen should be made with the help of a trusted source of regular care. Men without access to regular care should not be tested unless high-quality informed decision-making as well as appropriate counseling and follow-up care for those who test positive can be assured. Without those, community-based screening should not be initiated.”
“Previous guidelines from the American Cancer Society and other organizations have discussed the importance of informed decision making for men who are considering prostate cancer screening, however this update is the first to provide details regarding what information about screening is needed for informed decision-making to occur,” said Alan G. Thorson, M.D., F.A.C.S., volunteer president of the Society. “For that reason, the updated ACS guidelines delineate the core elements of information necessary for men to engage meaningfully in this decision, and encourage inclusion of this information in patient discussions and decision aids.”
The guidelines also includes updated clinical recommendations regarding screening tests, intervals, and follow up of abnormal results for those men who choose to be screened after considering the possible benefits and risks. The guidelines acknowledge the limited contribution of digital rectal exam (DRE) to prostate cancer early detection and state that screening can be performed using PSA with or without the DRE. The guidelines recommend annual screening for men whose PSA level is 2.5 ng/ml or higher, but state that screening intervals can be safely extended to every two years for men whose PSA is less than 2.5 ng/ml. The guidelines affirm that a PSA level of 4.0 ng/ml or higher remains a reasonable threshold to recommend referral for further evaluation or biopsy for men at average risk of developing prostate cancer; for PSA levels between 2.5 and 4.0 ng/ml, health care providers should consider an individualized risk assessment that incorporates other risk factors for prostate cancer in the referral decision.
The update included a complete review of the evidence. The American Cancer Society’s Prostate Cancer Advisory Committee, composed of independent researchers, clinicians and lay people, examined systematic reviews done by scientific experts at Emory University, Rollins School of Public Health, met to hear presentations by experts both on the Committee and by invited outside experts, and deliberated the evidence before making its final recommendations. The guideline underwent peer review before going before the American Cancer Society volunteer Board of Directors for approval.
The authors conclude by noting the urgent need for better ways to detect and treat early-stage prostate cancer, particularly the need to distinguish between cancers that do not require treatment and those that are aggressive, to help “tip the balance clearly in favor of screening. Until that time, however, it will remain incumbent on health care providers and the health care system as a whole to provide men with the opportunity to decide whether they wish to pursue early detection of prostate cancer.”
What are the statistics?
The Census Bureau estimates that approximately 40.5 million African Americans are living in the U.S., comprising 13 percent of the U.S. population. African Americans have the highest death rate and shortest survival of any racial and ethnic group in the U.S. for most cancers. The causes of these inequalities are complex and are thought to reflect social and economic disparities more than biologic differences associated with race. These include inequalities in work, wealth, income, education, housing and overall standard of living, barriers to high-quality health care, and racial discrimination.
African Americans are at increased risk of prostate cancer. An estimated 27,130 cases of prostate cancer were expected to occur among African American men in 2009, accounting for 34% of all cancers diagnosed in African American men. It is estimated that 3,690 deaths from prostate cancer occurred in African American men in 2009, making prostate cancer the second leading cause of cancer deaths in African American men (after lung cancer). Prostate cancer death rates in African American men are dropping at a rate of 5% per year. Some of the decreases in prostate cancer mortality may be due to improved surgical and radiologic treatment, dissemination of hormonal therapy for advanced-stage disease, and early detection.
What changes were made to the guidelines?
The updated guidelines increase the emphasis that testing should only occur when a man is provided the opportunity to learn about the limitations and potential benefits of screening and treatment, a recommendation made since 1997. For the first time the guidelines include specific topics that should be part of the informed decision-making discussion. And they clearly state that no man should be tested without receiving this information.
So is the American Cancer Society against prostate cancer screening for African Americans?
No. The American Cancer Society does not recommend for or against prostate cancer screening for any race or ethnicity. Rather, these recommendations emphasize that all men should learn about the limitations and potential benefits of screening and treatment, and decide whether or not to be screened.
If African American men are at higher risk of developing and dying of prostate cancer, why doesn’t the ACS recommend screening for them?
At this time, there is insufficient evidence to conclude that finding prostate cancer through screening results in a better outcome for men of any race or ethnicity. Two large trials of prostate cancer screening were recently published that came to differing conclusions regarding the value of prostate cancer screening. These trials included only a small number of African Americans, and it is therefore unclear how the findings of these trials relate to prostate cancer outcomes in African American men.
Although African American men are at high risk of developing prostate cancer, this higher risk does not change the fact that all other men need to be told of the uncertainties, risks and potential benefits of screening in order to make an informed decision. However, because of the higher incidence and earlier onset of disease in African American men, the ACS guideline recommends that these men should receive this information beginning at age 45, while men at average risk be given this information beginning at age 50.
How can we really expect men to make these decisions?
In light of uncertainties, risks and potential benefits of screening, involving men in the screening decision is crucial. Men may not be medical experts, but they are experts when it comes to knowing their own values, which are vital to the screening decision.
How can a simple blood test have risks?
The PSA blood test itself has minimal risk. However, significant harms can arise from the diagnostic and treatment cascade which can be triggered by screening. Once a cancer is diagnosed, most men will be treated for these cancers, either because the doctor can't be sure how aggressive the tumor might be, or because the men are uncomfortable with the idea of not having any treatment. But the level of over-diagnosis and over-treatment appears to be greater for prostate cancer than for any other cancer for which routine screening currently occurs. The adverse effects from treatment of prostate cancer are serious and potentially life altering. There is a high risk of sexual, urinary, or bowel-related symptoms, depending on the type of treatment selected. While in some men these problems may be minimal and/or temporary, for others these problems can be severe and long-lasting or even permanent.
What if a man chooses to be screened?
The guidelines include updated clinical recommendations regarding screening tests, testing intervals and follow up of abnormal results for those men who choose to be screened. Screening is recommended with the PSA blood test, with or without the digital rectal exam (DRE). Annual screening is recommended for men whose PSA level is 2.5 ng/ml or higher, but screening intervals can be safely extended to every two years for men whose PSA is less than 2.5 ng/ml. A PSA level of 4.0 ng/ml or higher remains a reasonable threshold to recommend referral for further evaluation or biopsy for men at average risk of developing prostate cancer; for PSA levels between 2.5 and 4.0 ng/ml, health care providers should consider an individualized risk assessment that incorporates other risk factors for prostate cancer, including race/ethnicity, in the referral decision.
FOR MORE INFORMATION, CONTACT:
American Cancer Society