THE "NEW" PROSTATE CANCER INFOLINK

Yesterday the American Urology Association (AUA) issued a second set of five recommendations to its members through the Choosing Wisely initiative (which is coordinated by the ABIM Foundation). Two of these recommendations were specific to risk for prostate cancer and its management.

The full media release issued by the AUA is available on line. However, the two new recommendations related to prostate cancer are the following:

• Don’t obtain computed tomography scan of the pelvis for asymptomatic men with low-risk clinically localized prostate cancer.
• Offer PSA testing for detecting prostate cancer only after engaging in shared decision making.

CT scans of the prostate and the pelvis as part of the work-up of low-risk patients have been clearly shown to have no value for the vast majority of patients, and actually come with some risk because of the form and dose of radiation used to carry out such scans. These scans may be valuable for appropriately selected men with higher-risk forms of prostate cancer, who may have soft-tissue metastasis, but not for low-risk patients.

With respect to the use of PSA testing, there is now widespread agreement that it is important for there to be appropriate education of every male about the risks and benefits of PSA testing, with shared decisions being taken by the patient and the doctor about use of such tests. This does not, by any means, imply that all PSA testing is bad. On the other hand, it is now well understood that PSA testing can have serious consequences that depend on the results of the test, subsequent findings, and subsequent decisions.

The “New” Prostate Cancer InfoLink is of the opinion that:

• Most men would be wise to have a baseline PSA test carried out at some time in or prior to their 40s — regardless of their known level of risk for prostate cancer. And it is important to understand that that first test is exactly as described, a baseline test (and not a screening test).
• Men at high risk (e.g., African Americans, Afro-Caribbeans, and men with a significant family history of prostate cancer) may want to have that baseline test carried out earlier (when they are between 35 and 45).
• Subsequent PSA testing should be planned based on the findings of that initial PSA baseline and other findings over time. If your baseline PSA test reulst is < 1.0 ng/ml, you may not need another PSA test for 5 years or more.
• Decisions about whether to give or have a prostate biopsy for risk of prostate cancer should be taken only rarely on the basis of a single PSA result; in most cases a repeat PSA test would be wise because normal PSA levels can vary over time for all sorts of reasons.
• Every man should discuss the pros and cons of PSA testing with his primary care physician between the ages of 40 and 45 (or earlier in the case of men known to be at elevated risk).

The complete list of 10 recommendations issued by the AUA through the Choosing Wisely initiative can also be found on line. Previously the AUA had advised its members and other clinicians that, with respect to risk for prostate cancer:

• Don’t treat an elevated PSA with antibiotics for patients not experiencing other symptoms.
• A routine bone scan is unnecessary in men with low-risk prostate cancer.

Several other organizations have also included recommendations through the Choosing Wisely initiative that are relevant to the diagnosis and management of prostate cancer:

• Don’t recommend screening for … prostate cancer if life expectancy is expected to be less than 10 years (AMDA).
• Don’t routinely perform PSA-based screening for prostate cancer (American College of Preventive Medicine).
• Don’t recommend screening for … prostate … cancer without considering life expectancy and the risks of testing, overdiagnosis and overtreatment (American Geriatrics Society).
• Don’t perform PSA testing for prostate cancer screening in men with no symptoms of the disease when they are expected to live less than 10 years (American Society of Clinical Oncology).
• Don’t routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam (American Academy of Family Physicians).
• Don’t routinely recommend proton beam therapy for prostate cancer outside of a prospective clinical trial or registry (American Society for Radiation Oncology).
• Don’t initiate management of low-risk prostate cancer without discussing active surveillance (American Society for Radiation Oncology).
• Don’t perform PET, CT, and radionuclide bone scans in the staging of early prostate cancer at low risk for metastasis (American Society of Clinical Oncology).

Filed under: Diagnosis, Living with Prostate Cancer, Management, Risk | Tagged: cancer, guidance, prostate, PSA, recommendation |