ACP issues new guidance about PSA testing to primary care physicians

The Clinical Guidelines Committee of the American College of Physicians (ACP) — one of the most influential primary care medical societies in the USA — has just issued a new set of guidelines on screening for prostate cancer. Many prostate cancer patients are likely to be deeply disturbed by these guidelines.

The full text of this report by Qaseem et al. (“Screening for prostate cancer: a guidance statement from the Clinical Guidelines Committee of the American College of Physicians“) is available on line. Commentary on the new guidance is available on a variety of web sites from Reuters to The Augusta Chronicle.

The new guidance from the ACP to its members is encapsulated in two “guidance statements”:

Guidance Statement 1: ACP recommends that clinicians inform men between the age of 50 and 69 years about the limited potential benefits and substantial harms of screening for prostate cancer. ACP recommends that clinicians base the decision to screen for prostate cancer using the prostate-specific antigen test on the risk for prostate cancer, a discussion of the benefits and harms of screening, the patient’s general health and life expectancy, and patient preferences. ACP recommends that clinicians should not screen for prostate cancer using the prostate-specific antigen test in patients who do not express a clear preference for screening.

Guidance Statement 2: ACP recommends that clinicians should not screen for prostate cancer using the prostate-specific antigen test in average-risk men under the age of 50 years, men over the age of 69 years, or men with a life expectancy of less than 10 to 15 years.

The “New” Prostate Cancer InfoLink is of the opinion that these guidance statements are a considerable improvement over the “absolute” statements of the U.S. Preventive Services Task Force for the simple reason that they are based on the idea of risk for prostate cancer and patient preference. It is certainly true that, on the basis of these guidance statements, some less well informed men will not get diagnosed as early as would be ideal. On the other hand, it is also true that many men who are currently being over-treated (and who therefore suffer more from the complications and side effects of treatment than they ever would from prostate cancer itself) will avoid such over-treatment on the basis of this guidance.

The problem, as we have stated many, many times before, is that neither the PSA test nor any other test available at the present time offers us an accurate method to differentiate between risk for clinically significant prostate cancer (i.e., prostate cancer that actually needs treatment to prevent metastasis and prostate cancer-specific mortality) and a whole variety of other conditions. One can certainly argue that it is the best test that is currently available … but it is still an extremely non-specific test and the data generated by this test almost inevitably lead some men and their doctors down the path toward biopsy and over-treatment when these are potentially unjustifiable.

The “New” Prostate Cancer InfoLink expects that we will see the American Urology Association react to this new guidance in a less than constructive manner. However, we would also refer our readers to the recent article by Scardino and Vickers that we discussed just the other day on this web site. It’s beyond time to find and settle on some common ground. We can prevent the majority of prostate cancer-specific deaths without finding every prostate cancer cell in every man. Indeed, the latter is a scientifically invalid and clinically unwise strategy!

7 Responses

  1. Seems to me like a firmly grounded evidenced-based recommendation respectful of both consumer choice and on-the-ground clinical assessment.

    No doubt those whose incomes are based on defining an ever-larger market of prostates to treat for something and those whose mission it is to raise money and “awareness” for those truly at mortal risk of prostate cancer will be disappointed to have the size of the market and the scale of concern diminished.

  2. The ACP guidelines simply mean that internists should treat male patients as individuals. I question why it took internists so long to come to their senses about this issue. However, better late than never. Good guidelines.

  3. I take serious issue with Guideline #2 that men over the age of 69 simply not be tested. In 2004, just before I turned 75, I was diagnosed via the PSA test (with negative DRE) with Gleason 9 prostate cancer. I was treated and it is now 9 years later with no sign of recurrence. I’m turning 84 this year, enjoying life with my beloved wife, children and grandchildren, and I feel just fine. Without detection by the PSA test, I would have long since turned to dust.

  4. I hope the days of men getting PSA testing without their knowledge or consent are coming to an end. Unfortunately, many PCPs have labs that just order “shotgun” blood studies to maximize office profits, yet patients receive ill-advised testing.

  5. I agree with Mr. Rosenbaum that testing should continue until age 75 for men with a good 10- to 15-year life expectancy. I tell men who are candidates for prostate cancer screening and want prostate cancer screening that if you make it to 75 and have no reasonable evidence of clinical prostate cancer, i.e., neither an elevated or nor a rising PSA nor an abnormal DRE, that no further screening is justifiable with evidence-based data.

    Looks like Manny got in right under the wire. Cheers to him!

  6. I am 88 years of age. At age 87 I was diagnosed with a Gleason score of 10 and a PSA of 14 with metastases to the spine. I have been treated with Lupron, Casodex, Zytiga, Zometa, and radiation to my spine. My PSA is down; I feel good, and have no pain. As per this article I should have done nothing except wait for the Grim Reaper. That’s what I call giving up on life.

  7. Dear Sidney:

    The ACP guidance does not either suggest or imply that men who are diagnosed with symptomatic prostate cancer of any type should not be treated. Your diagnosis and treatment appear to be entirely within the ACP guidance since you appear to have been diagnosed because of back pain that was then confirmed by a biopsy of your prostate.

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