As many readers will be aware, there have been two new sets of guidance about screening for prostate cancer issued in the past few months — the most recent from the American Urological Association just a couple of weeks ago.
In response to the fact that we now have a total of four different sets of guidance (not including the guidance issued by the American Cancer Society) available to the medical community, the members of the Prostate Cancer Roundtable issued the following media release earlier today:
Professionals and Patients Increasingly Confused by Guidance on Screening for Risk of Prostate Cancer
Washington, D.C., May 23, 2013: Representing the interests of the 240,000 American men who are at risk each year for a diagnosis of prostate cancer, and the over 2 million men living today who have been diagnosed with this deadly form of cancer, the membership of the Prostate Cancer Roundtable is increasingly concerned by the utterly confusing guidance being offered — to both the professional healthcare community and to individual consumers — about whether men should or should not be tested (“screened”) for risk of prostate cancer.
At the annual meeting of the American Urological Association (AUA) in San Diego just a few days ago, the AUA issued new guidance about the use of the PSA test to screen men for risk of prostate cancer.1 The newly issued guidance differs radically from prior guidance offered by the AUA itself,2 from guidance offered by the U.S. Preventive Services Task Force in May 2012,3 and from guidance recently issued by the American College of Physicians.4 Each of these three sets of guidance claims to be “evidence based”. The new guidance also differs from that offered by the National Comprehensive Cancer Network.5
“The members of the Prostate Cancer Roundtable fully appreciate that there is great controversy about the use of PSA testing to screen the average, otherwise healthy, Caucasian male for his risk of clinically significant prostate cancer,” said Ana Fadich, VP of Men’s Health Network. “However, the frequent issuance of new guidance documents by a variety of organizations that present differing recommendations based on what is basically the same set of low quality scientific evidence and related opinion leaves men and their doctors confused, upset, and uncertain about what represents good medical practice today.”
The membership of the Prostate Cancer Roundtable also notes that none of the recently issued guidance documents explicitly address the appropriateness of screening of those men at greatest potential risk for clinically significant prostate cancer (largely because there are no good data that address this critical issue). In other words, there is now no clear message at all being given to healthcare professionals about the need for testing in those men who experts in the management of prostate cancer believe to be at significantly higher risk for clinically significant disease than the average, healthy man of Caucasian ethnicity: men with a family history of clinically significant prostate cancer and men of African-American and Afro-Caribbean ethnicity.
“Multiple studies have shown that black males are at greater risk for prostate cancer-specific mortality than white males of comparable age and health,” stated Thomas Farrington of the Prostate Health Education Network. “The lack of explicit guidance about the need for risk testing in this group is potentially a disaster. We have a prostate cancer epidemic among black Americans. This community in particular needs clarity about the role of the PSA test in screening for prostate cancer.”
“Many would argue that there is strong evidence for the value of a baseline PSA test among men in their 40s,” said Merel Nissenberg of the National Alliance of State Prostate Cancer Coalitions. “Such baseline testing is a way to define individual risk and to help men to understand this. However, even the new guidance from the AUA does not offer any definitive guidance on this issue.”
The Prostate Cancer Roundtable is fundamentally concerned that the contradictory guidance coming from different sectors of the medical community reflects two factors: (1) the lack of really good data that offers incontrovertible evidence about screening for prostate cancer – especially among groups of men who may be at particularly high risk levels, and (2) the failure of the differing sectors of the medical community to come together and develop guidance that is issued in the interests of patients and families as opposed to the interests of the professional healthcare community.
We believe that it is time for real leadership from organizations such as the National Institutes of Health and the Institute of Medicine to look at what is needed to develop definitive evidence about the value of screening for risk of prostate cancer – particularly among those groups of men who are known to be at elevated risk levels because of ethnicity and family history. Until such definitive evidence is available, we further believe that every man should be encouraged to have a serious discussion with his primary care physician about whether some forms of testing for risk of prostate cancer may be appropriate for him as an individual (as opposed to the risk of the average, healthy, Caucasian male of 40 to 70 years of age). It is unacceptable that the data on the risks and benefits of prostate cancer screening available today is still not good enough to offer sound advice to any individual patient about risk related to the most common form of cancer now identified in American males (other than basal and squamous cell skin cancers)!
We would conclude by noting that the members of the Prostate Cancer Roundtable are also fully cognizant of the fact that a diagnosis of low-risk prostate cancer does not and should not necessarily imply any immediate need for treatment. The potential problems associated with over-treatment of low-risk prostate cancer need to be addressed as carefully as the problems associated with failure to diagnose clinically significant prostate cancer early so that it can be effectively treated with curative intent.
1. Carter HB, Albertsen PC, Barry MJ, et al. Early detection of prostate cancer: AUA guideline. 2013; downloaded at http://www.auanet.org/common/pdf/education/clinical-guidance/Prostate-Cancer-Detection.pdf on May 16, 2013.
2. Greene KL, Albertsen PC, Babaian RJ, et al. Prostate specific antigen best practice statement: 2009 update. J Urol. 2009; 182: 2232-2241, downloaded at http://download.journals.elsevierhealth.com/pdfs/journals/0022-5347/PIIS0022534709019557.pdf on May 17, 2013.
3. US Preventive Services Task Force. Screening for prostate cancer. 2012; downloaded at http://www.uspreventiveservicestaskforce.org/prostatecancerscreening/prostatefinalrs.htm on May 16, 2013.
4. Qaseem A, Barry MJ, Denberg TD, et al. Screening for prostate cancer: a guidance statement from the clinical guidelines committee of the American College of Physicians. Ann Intern Med. 2013; downloaded at http://annals.org/article.aspx?articleid=1676183 on May 16, 2013.
5. National Comprehensive Cancer Network. Early detection of prostate cancer, version 2.2012. 2012; downloaded at http://www.nccn.org/professionals/physician_gls/pdf/prostate_detection.pdf on May 16, 2013
This statement was supported by the vast majority of the members of the Roundtable (including Prostate Cancer International, the parent organization of The “New” Prostate Cancer InfoLink).