Urological Group Breaks with Major Medical Groups to
Recommend Regular Prostate Testing
AUA wants individualized PSA testing starting at age
40; American Cancer Society and others oppose routine prostate cancer
testing
April 27, 2009 - Frequency of testing for several
conditions have been hot debate topics in medical circles recently, and
fuel was added to one of the hottest today by the American Urological
Association, which wants prostate-specific antigen (PSA) test offered to
well-informed, men aged 40 years or older who have a life expectancy of
at least 10 years. The AUAs new clinical guidance directly contrasts
with other major groups.
The American Cancer Society says on its Website,
No major scientific or medical organizations, including the American
Cancer Society (ACS), American Urological Association (AUA), US
Preventive Services Task Force (USPSTF), American College of Physicians
(ACP), National Cancer Institute (NCI), American Academy of Family
Physicians (AAFP), and American College of Preventive Medicine (ACPM)
support routine testing for prostate cancer at this time.
This was obviously written before the AUA decided
to break from the other organizations with its statement today.
The PSA test, as well as how it is used to guide
patient care (e.g., at what age men should begin regular testing,
intervals at which the test should be repeated, at what point a biopsy
is necessary) was already highly controversial, the group admits.
The AUA states, however, that it believes that,
when offered and interpreted appropriately, the PSA test may provide
essential information for the diagnosis, pre-treatment staging or risk
assessment and post-treatment monitoring of prostate cancer.
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American Cancer Society says...
The American Cancer Society (ACS) does not support
routine testing for prostate cancer at this time. ACS does believe that
health care professionals should discuss the potential benefits and
limitations of prostate cancer early detection testing with men before
any testing begins.
This discussion should include an offer for testing
with the prostate-specific antigen (PSA) blood test and digital rectal
exam (DRE) yearly, beginning at age 50, to men who are at average risk
of prostate cancer and have at least a 10-year life expectancy.
Following this discussion, those men who favor testing should be tested.
Men should actively take part in this decision by learning about
prostate cancer and the pros and cons of early detection and treatment
of prostate cancer.
This discussion should take place starting at age
45 for men at high risk of developing prostate cancer. This includes
African American men and men who have a first-degree relative (father,
brother, or son) diagnosed with prostate cancer at an early age (younger
than age 65).
This discussion should take place at age 40 for men
at even higher risk (those with several first-degree relatives who had
prostate cancer at an early age).
If, after this discussion, a man asks his health
care professional to make the decision for him, he should be tested
(unless there is a specific reason not to test).
>>
Read the complete statement by the ACS
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The new Best Practice Statement updates the AUA's
previous guidance, which was issued in 2000.
Major changes to the AUA statement include new
recommendations about who should be considered for PSA testing, as well
as when a biopsy is indicated following an abnormal PSA reading.
According to the AUA, early detection and risk
assessment of prostate cancer should be offered to well-informed men 40
years of age or older who have a life expectancy of at least 10 years. T
he future risk of prostate cancer is closely
related to a man's PSA score; a baseline PSA level above the median for
age 40 is a strong predictor of prostate cancer. Such testing may not
only allow for earlier detection of more curable cancers, but may also
allow for more efficient, less frequent testing. Men who wish to be
screened for prostate cancer should have both a PSA test and a digital
rectal exam (DRE).
The Statement also notes that other factors such as
family history, age, overall health and ethnicity should be combined
with the results of PSA testing and physical examination in order to
better determine the risk of prostate cancer.
The Statement recommends that the benefits and
risks of screening of prostate cancer should be discussed including the
risk of over-detection, detecting some cancers which may not need
immediate treatment
"The single most important message of this
statement is that prostate cancer testing is an individual decision that
patients of any age should make in conjunction with their physicians and
urologists. There is no single standard that applies to all men, nor
should there be at this time," Dr. Carroll said.
He also notes that the "panel carefully reviewed
the most recently reported trials of PSA testing in both the United
States and Europe before finalizing their guidelines. The strengths and
limitations of these trials are reviewed in the guideline."
In regard to biopsy, a continuum of risk exists at
all values, and major studies have demonstrated that there is no safe
PSA value below which a man may be reassured that he does not have
biopsy-detectable prostate cancer, according to the AUA statement.
Therefore, the AUA does not recommend a single PSA
threshold at which a biopsy should be obtained. Rather, the decision to
biopsy should take into account additional factors, including free and
total PSA, PSA velocity and density, patient age, family history,
race/ethnicity, previous biopsy history and co-morbidities.
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About PSA Tests
Alternative Names
Prostate-specific antigen; Prostate cancer
screening test
Definition
PSA stands for prostate-specific antigen. It is a
protein found in prostate cells. It can be detected at a low level in
the blood of all adult men.
This article discusses the blood test to measure
the amount of PSA in a man's blood.
How the Test is Performed
Blood is typically drawn from a vein, usually from
the inside of the elbow or the back of the hand. The site is cleaned
with germ-killing medicine (antiseptic). The health care provider wraps
an elastic band around the upper arm to apply pressure to the area and
make the vein swell with blood.
Next, the health care provider gently inserts a
needle into the vein. The blood collects into an airtight vial or tube
attached to the needle. The elastic band is removed from your arm. Once
the blood has been collected, the needle is removed, and the puncture
site is covered to stop any bleeding.
No special preparation is usually needed.
How the Test Will Feel
When the needle is inserted to draw blood, some
people feel moderate pain while others feel only a prick or stinging
sensation. Afterward, there may be some throbbing or a bruise.
Why the Test is Performed
This test is done to screen for prostate cancer. It
is also used to monitor patients after prostate cancer treatment.
Several conditions besides cancer can cause the PSA
level to rise, including:
●
Benign prostatic hyperplasia
●
Prostatitis
●
Urinary tract infections
Discuss with your doctor or health care provider
whether a PSA test is appropriate for you.
Normal Results
Normal values vary with age. Older men typically
have slightly higher PSA measurements than younger men. Men with a
larger prostate will also have higher PSA values.
Normal value ranges may vary slightly among
different laboratories. Talk to your doctor about the meaning of your
specific test results.
What Abnormal Results Mean
A high PSA level has been linked to an increased
chance of having prostate cancer. However, a high PSA level does not
mean that you definitely have prostate cancer. A high PSA level only
identifies patients at higher risk of having prostate cancer. People at
higher risk may need to have more tests.
A PSA of 4 nanograms per milliliter (ng/mL) is
abnormally high for most men and may indicate the need for a prostate
biopsy.
Keep in mind that although PSA testing is an
important tool for detecting prostate cancer, it is not foolproof.
Greater-than-normal PSA levels may indicate:
●
Benign prostatic hypertrophy
●
Prostate cancer
●
Prostatitis
● Prostate infection
●
Urinary tract infection
● Recent urinary catheterization
● Recent urinary tract operation
Risks
Veins and arteries vary in size from one patient to
another and from one side of the body to the other. Obtaining a blood
sample from some people may be more difficult than from others.
Other risks associated with having blood drawn are
slight but may include:
● Excessive bleeding
● Fainting or feeling light-headed
● Hematoma (blood accumulating under the skin)
● Infection (a slight risk any time the skin is
broken)
Considerations
Discuss the benefits and risks of testing with your
doctor to determine whether screening is right for you.
● Potential benefits include early diagnosis of
cancer
● Potential risks include increased health care
costs, unnecessary invasive testing (biopsy) and treatment
The American Urologic Association, American Cancer
Society, and National Comprehensive Cancer Network recommend that:
● All men ages 50 - 75 have annual PSA tests
● You get tested at an earlier age (age 40 or 45)
if you are of African-American heritage or have a father or brother with
prostate cancer
However, these guidelines are not recommended for
everyone.
Many health organizations, including the US
Preventive Services Task Force, do not recommend routine PSA testing.
>>
From MedlinePlus Medical Encyclopedia
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Additionally, the AUA statement emphasizes that
not all prostate cancers require active treatment and that not all
prostate cancers are life-threatening.
The decision to proceed to active treatments is one
that men should discuss in detail with their urologists to determine
whether active treatment is necessary, or whether surveillance may be an
option for their prostate cancer.
"Prostate cancer comes in many forms, some
aggressive and some not," said Peter Carroll, MD, chair of the panel
that developed the Statement.
"But the bottom line about prostate cancer testing
is that we cannot counsel patients about next steps for cancer that we
do not know exist."
He also notes that "the AUA is committed to the
timely, expert and appropriate care for men either with or at risk of
getting prostate cancer and is prepared to revise these guidelines
continuously as new information becomes available."
Additionally, the Best Practice Statement clarifies
a number of key points about the use of PSA in treatment selection and
post-treatment follow up of prostate cancer patients:
● Serum PSA predicts the response of prostate
cancer to local therapy.
● Routine use of a bone scan is not required for
staging asymptomatic men with clinically localized prostate cancer when
their PSA level is equal to or less than 20.0 ng/mL.
● Computed tomography or magnetic resonance
imaging scans may be considered for the staging of men with high-risk
clinically localized prostate cancer when the PSA is greater than 20.0
ng/mL or when locally advanced or when the Gleason score is greater than
or equal to 8.
● Pelvic lymph node dissection for clinically
localized prostate cancer may not be necessary if the PSA is less than
10.0 ng/mL and the Gleason score is less than or equal to 6.
● Periodic PSA determinations should be offered
to detect disease recurrence.
● Serum PSA should decrease and remain at
undetectable levels after radical prostatectomy.
● Serum PSA should fall to a low level following
radiation therapy, high intensity focused ultrasound and cryotherapy and
should not rise on successive occasions.
● PSA nadir (low point) after androgen
suppression therapy predicts mortality.
● Bone scans are indicated for the detection of
metastases following initial treatment for localized disease, but the
PSA level that should prompt a bone scan is uncertain. Additional
important prognostic information can be obtained by evaluation of PSA
kinetics (velocity).
● The kinetics of PSA rise after local therapy
for prostate cancer can help distinguish between local and distant
recurrence.
The new AUA statement is based on panel review of
all available professional literature, members' clinical experience and
expert opinion. The new statement is available online to the public at
www.AUAnet.org.
The AUA Foundation will be issuing an official
Patient Guide outlining what men need to know when it comes to prostate
cancer testing. The Guide will be introduced on Monday, April 27th at
the AUA Annual Meeting in Chicago in conjunction with the AUA's new best
practices statement on prostate cancer testing.
About Information Source:
About the American Urological Association: Founded
in 1902 and headquartered near Baltimore, Maryland, the American
Urological Association is the pre-eminent professional organization for
urologists, with more than 16,000 members throughout the world. An
educational nonprofit organization, the AUA pursues its mission of
fostering the highest standards of urologic care by carrying out a wide
variety of programs for members and their patients.
