At the time of his annual physical, it made sense for Drew Brejda, 57, to get the prostate-specific antigen screening test for cancer.
“They were going to draw so many ounces of blood from me no matter what,” for other tests, he said. A heightened level on his PSA test led to more discussion, a biopsy and eventually the removal of his cancerous prostate gland, with not many complications from the surgery so far. But for many men, including many older than 70, that test does not make a lot of sense and carries substantial potential risk from overtesting to overtreatment of what is typically a slow-growing tumor, a major physician group announced Monday.
The American College of Physicians issued “Screening for Prostate Cancer: A Guidance Statement” in the Annals of Internal Medicine as part of its Summaries for Patients. The college’s Clinical Guidelines Committee looked at guidelines issued by other expert groups on the PSA and focused in on four: the American College of Preventive Medicine, the American Cancer Society, the American Urological Association and the U.S. Preventive Services Task Force. The committee also examined the evidence and research behind those guidelines.
The task force did not recommend PSA screening and the other three recommended it for certain age groups only after an informed discussion with the patient. The ACP’s own guidance was to recommend that men ages 50 to 69 have a discussion with their physician “about the limited potential benefits and substantial harms of screening for prostate cancer.” The physician should base whether to use the PSA test on a patient’s preference, his risk for prostate cancer, age, health and life expectancy, the guidelines said.
All of the guidelines were for men considered at normal risk. Those at higher risk – blacks and those with a first-degree relative who got prostate cancer before age 65 – should have the discussion beginning at age 45, while men at very high risk should start at age 40.
The problem with prostate cancer is knowing what should be the recommendation, said Dr. Rabii Madi, the director of urologic oncology and robotic surgery at Georgia Regents University Cancer Center.
“Everything about prostate cancer is still controversial, from screening to treatment to follow-up after treatment,” he said.
Part of the problem is prostate cancer itself.
“In most cases it is a slowly progressing cancer,” Madi said. “And many patients diagnosed with prostate cancer, they will eventually die from other causes, from heart disease or other reasons. That’s the dilemma we are facing right now is to be able to diagnose and treat those patients who will benefit from the treatment.”
Yet prostate cancer is the most diagnosed cancer in men, according to the American Cancer Society, with 238,590 cases in the U.S., including 7,930 in Georgia, and it is the second-leading cause of cancer deaths, with 29,700 in the U.S. and 790 in Georgia.
“Prostate cancer is still a very serious cancer and still many people are dying from prostate cancer,” Madi said. “The less emphasis on the screening doesn’t mean we have to totally ignore that very prevalent disease. I would advise every patient to have a discussion with his primary care physician or his urologist to discuss the pros and cons of screening and to know the limitation of the screening and also to know that even with prostate cancer it doesn’t mean that indicates treatment.”
Every decision should be very personalized, he added.
Now more than two years out from this surgery, Brejda is glad he had the test then.
“If I was not seeing a doctor on at least an annual basis, who knows when this would have been diagnosed,” he said.