Yesterday evening, the American Urological Association (AUA) issued a new, formal statement on the role of PSA testing in assessment of risk for prostate cancer: “Information Sheet: Prostate-specific antigen (PSA) testing for the early detection of prostate cancer.”
Despite the vehement statements from some in the urology community in response to the recent recommendation issued by the U.S. Preventive Services Task Force (USPSTF) about widespread prostate cancer screening with the PSA test, this new document from the AUA is interesting because, for the first time, the AUA appears to clearly and explicitly acknowledge the relevance of a patient’s awareness that the potential consequences of PSA testing do carry real risks for individual patients:
The AUA believes that the decision to test for prostate cancer requires an in-depth discussion of the pros and cons of testing where a patient and his healthcare provider can have an honest and frank interchange and any questions a patient may have can be answered clearly. If, after this discussion, a patient wishes to be tested, they should be tested. In order to be effective and to minimize the risks of over-diagnosis and over-treatment, prostate cancer testing must be individualized based on a man’s risk factors.
Indeed, the word “screening” does not appear in this new statement from the AUA at all, and The “New” Prostate Cancer InfoLink congratulates the AUA for this step. The real controversy about use of the PSA tests in assessment of risk for prostate cancer has never been about its value in signaling the possibility of that risk. It has been about the excessive, annual use of the PSA test in healthy men with no known risk factors for prostate cancer, which has led to an excessively high level of diagnosis and over-treatment of low- and very low-risk forms of prostate cancer, particularly in older men who are found to have pathologic evidence of cancer and who (because of our ingrained, societal fears about any diagnosis of cancer) then insist of treatment from which they are most unlikely to gain any benefit and which commonly is associated with a well understood series of potentially significant harms.
The AUA also, correctly, points out in this new statement the importance of separating the idea of risk assessment (through the appropriate use of PSA tests and digital rectal exams) from the subsequent need for actual diagnosis and treatment, implying the importance of careful, sequential discussions between doctors and patients about the risks and harms associated with prostate biopsy and the importance of full explanation of the relative merits of treatment as compared to some form of monitoring (in carefully characterized individuals) based on the clinical characteristics and the personal desires of the individual patient and his family.
Of course we shouldn’t be surprised that the AUA continues to “blame” the USPSTF for issuing a recommendation with which most urologists disagree, but The “New” Prostate Cancer InfoLink cannot help noticing that there is an interesting correlation between the above-mentioned quotation from the AUA’s statement, and the following quotation from the USPSTF in their formal discussion of the clinical implications of their recommendation:
Although the USPSTF discourages the use of screening tests for which the benefits do not outweigh the harms in the target population, it recognizes the common use of PSA screening in practice today and understands that some men will continue to request screening and some physicians will continue to offer it. The decision to initiate or continue PSA screening should reflect an explicit understanding of the possible benefits and harms and respect the patients’ preferences. Physicians should not offer or order PSA screening unless they are prepared to engage in shared decision making that enables an informed choice by the patients. Similarly, patients requesting PSA screening should be provided with the opportunity to make informed choices to be screened that reflect their values about specific benefits and harms.
It would, perhaps, have been helpful if the USPSTF had been careful to distinguish, in this paragraph, between the use of the term “screening” (to mean the regular, mass, population-based testing of all men within a defined age range) and the “testing” of individuals who either are known to be at risk or wish to make an assessment of their personal risk for prostate cancer at a point in time.
The careful reader and analyst might, with real benefit, start to appreciate that the AUA and the USPSTF are not nearly as far apart as some may wish to paint them.
The “New” Prostate Cancer InfoLink suggests that it is time for the prostate cancer patient community, like the AUA, to drop the use of the term “screening” and to focus on:
- The importance of the right of the individual patient to be tested for risk of prostate cancer if that is his wish, and
- The need for all men to be appropriately educated over time on the risks associated with the possibility of a diagnosis of prostate cancer (as opposed to the need for annual mass screening programs).
In the e-mail to its members distributing the link to the new formal statement, the AUA has also said that
Early next week, we will also be providing … a “toolkit” (including additional information, patient materials and slides) to assist you in educating your patients, the public and your local medical community about why the early detection of prostate cancer is critical. These materials will also be available online at www.AUAnet.org/USPSTF.
The “New” Prostate Cancer InfoLink will be watching for this additional information.