ASCO issues new guidance on PSA testing and prostate cancer risk

The American Society of Clinical Oncology (ASCO) has just issued a new provisional guideline on the use of PSA testing in the assessment of risk for prostate cancer. The full text of this article is available on line.

This new provisional guidance from ASCO makes three core recommendations:

  • “In men with a life expectancy < 10 years, it is recommended that general screening for prostate cancer with total PSA be discouraged, because harms seem to outweigh potential benefits.”
  • “In men with a life expectancy > 10 years, it is recommended that physicians discuss with their patients whether PSA testing for prostate cancer screening is appropriate for them. PSA testing may save lives but is associated with harms, including complications, from unnecessary biopsy, surgery, or radiation treatment.”
  • ” … information written in lay language be available to clinicians and their patients to facilitate the discussion of the benefits and harms associated with PSA testing before the routine ordering of aPSA test.”

While others may disagree, these three recommendations make perfect sense to The “New” Prostate Cancer InfoLink.

We should point out carefully that this provisional recommendation is limited to men who have never been diagnosed with prostate cancer. The role of PSA testing in the long-term management of men recently or previously diagnosed with and treated for (or being managed with) prostate cancer is not affected by this guideline.

ASCO is careful to note that the estimation and calulation of life expectancy is based on individual factors and circumstances. They point out that a number of life
expectancy calculators are publicly available. (They refer readers to the one on the Social Security Online web site as just one such example. We would point out that this particular calculator does not take any account of any such factors as current health, lifestyle, and family history that could increase or decrease life expectancy.)

Quoted in a report already up on the ABC News web site, Dr. Robert Nam, one of the co-chairs of the ASCO committee that issued this provisional guideline has said:

A lot of men that have a long life expectancy would benefit from screening, especially those that will be diagnosed with aggressive forms of prostate cancer.  Men with aggressive prostate cancer can benefit from early treatment.

10 Responses

  1. “…is associated with harms, including complications, from unnecessary biopsy, surgery, or radiation treatment.”

    Now that’s not very explicit or meaningful information, now is it?

  2. Sir:

    My father is an heart patient he has done his bypass surgery in december 2011 he has psa 94% and and gleason score 3+4=7 perineural invasion is not seen. please reply me what treatment must be taken.

  3. Tracy … Read the whole paper.

  4. Vijay:

    I replied to you before. Please join our social network and post the information about your father there, not here.

  5. Mike:

    I agree with ASCO and the article, while it could be better written, is not a bad one. I am that man that Dr. Nam talks about. I think if any screening is going to take place, it has to be among younger men and not older men. This will establish a baseline for men to monitor and allow them time to get educated. The problem is that many doctors will rush high PSAs to treatment when in fact other markers are available such as doubling rates, Free PSA, PCA3, T2 markers, etc. I think that doctors who do this screening should try to find an educational venue for suspicious PSA results in a 40-year-old man before he gets a biopsy. And we need better literature as well. I agree with these suggestions and I am very thankful that this site does too.

  6. Here is a link to an article in The Huffington Post. This is what I thought could have been better written … but it’s still a good one.

  7. There are two uses of the intentionally innocuous term “quality of life”, and one instance each of the terms erectile dysfunction, bowel dysfunction, and urinary incontinence. The terms “over-diagnosis” and “over-treatment” were also mentioned one time each.

    Yep, they really get it.

  8. Dear Tracy:

    I have no idea what that comment is meant to mean. Given that we don’t have a better test than the PSA test at the present time, what do you want? Testing, no testing, or at least some thought about testing? You appear to be schizophrenic about this issue. That doesn’t help anyone.

  9. I’m sorry to not be sufficiently clear. The recommendation appears to give a rather perfunctory nod to recognizing and addressing over-diagnosis and over-treatment — barely and euphemistically acknowledges the very real side effects that all to most (depending on the side effect) men will experience. There was only a single mention of active surveillance also.

    So, to clarify, my comment, “Yep, they really get it.” was definitely intended ironically. They so don’t get it.

  10. Dear Tracy:

    I absolutely and completely disagree with you. The article is extremely clear about this problem. Please remember that the authors are writing this guidance for oncologists; not for patients and not for urologists either. I quote from the introduction to the article:

    “The issue of PSA testing is fraught with challenges: many individuals do not have adequate information to help them decide whether to be screened for prostate cancer, and providers may not have adequate time, information, or training to help them provide appropriate medical advice. Furthermore, there is controversy regarding the indications
    for biopsy and treatment. Weighing the potential benefits and harms for each of these decisions is complex, involving many tradeoffs, including the significant issues of overdiagnosis, overtreatment, adverse events, and quality of life. This PCO focuses on PSA
    testing for prostate cancer screening and also touches on the harms and benefits associated with prostate biopsy. The role of digital rectal examination and associated scientific evidence are not considered in the context of this PCO. In addition, the treatment of prostate cancer is outside the scope of this report, although brief mention of treatment considerations, such as the role of active surveillance, is included in
    the discussion.”

    The whole point of the statement about the availability of appropriate patient-directed material is designed to address the very different issue that you are raising.

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