Older Men Startled by Cancer Society Emphasis on
Prostate Screening Danger, Uncertainty
Most senior citizens have always considered the
treatment option the biggest decision; guidelines say screening should
not be offered to those not expected to live over 10 years
March 9, 2010 – Early this month the American
Cancer Society updated its prostate cancer screening guidelines and
emphasized that men should discuss the “uncertainties, risks and
potential benefits of screening” for prostate cancer even before they
decide whether to be tested. This emphasis on the risks and
uncertainties of just screening, was startling to millions of senior men
who have always considered the treatment options as the big decision –
not just regular screening.
“While early detection may reduce the likelihood of
dying from prostate cancer, that benefit must be weighed against the
serious risks associated with subsequent treatment, particularly the
risk of treating men for cancers that would not have caused ill effects
had they been left undetected,” said Andrew M. Wolf, M.D., Associate
Professor of Medicine at the University of Virginia Health System and
Chair of the Advisory Committee.
Researchers studied almost 6,000 senior citizens,
suggest patients be informed about the differences and similarities in
expected outcomes, make treatment decisions with an experienced surgeon
“Two decades into the PSA era of prostate cancer
screening, the overall value of early detection in reducing the
morbidity and mortality from prostate cancer remains unclear.”
The authors say in light of ongoing uncertainties,
including the uncertain balance between benefits and risks, involving
men in the screening decision is crucial.
While not a radical change from the previous
prostate-screening recommendations, the new guidelines offer clearer
guidance on those things that should be discussed, says Edward
Partridge, M.D., president-elect of the American Cancer Society (ACS)
National Board of Directors and director of the
University of Alabama at Birmingham (UAB) Comprehensive Cancer Center.
Dr. Partridge is also a co-investigator on the national Prostate, Lung,
Colorectal and Ovarian Cancer Screening Trial (PLCO trial) that helped
inform the updated guidelines.
"...men who have less than a ten-year life
expectancy based on age and health status should not be offered
prostate cancer screening."
The update, released March 3, is the first since
2001 and the ACS emphasized it was done as part of the Society’s regular
guidelines update process.
It included a series of systematic reviews focusing
on the latest evidence related to the early detection of prostate
cancer, screening test performance, harms of therapy for localized
prostate cancer, and shared and informed decision making in prostate
cancer screening. The guideline was published online in advance of print
publication in CA: A Cancer Journal for Clinicians.
The updated American Cancer Society guidelines
include these recommendations:
Prostate Screening Guidelines 2010
● Asymptomatic men who have at least a ten-year
life expectancy should have an opportunity to make an informed decision
with their health care provider about screening for prostate cancer
after receiving information about the uncertainties, risks, and
potential benefits associated with screening.
● Men at average risk should receive this
information beginning at age 50. Men at higher risk, including African
American men and men with a first degree relative (father or brother)
diagnosed with prostate cancer before age 65, should receive this
information beginning at age 45. Men at appreciably higher risk
(multiple family members diagnosed with prostate cancer before age 65)
should receive this information beginning at age 40.
● Men should either receive this information
directly from their health care providers or be referred to reliable and
culturally appropriate sources.
● Patient decision aids are helpful in preparing
men to make a decision whether to be tested.
● Prostate cancer screening should not occur
without an informed decision making process.
● Asymptomatic men who have less than a ten-year
life expectancy based on age and health status should not be offered
prostate cancer screening.
● For men who are unable to decide, the
screening decision can be left to the discretion of the health care
provider, who should factor into the decision his or her knowledge of
the patient’s general health preferences and values.
“Previous guidelines from the American Cancer
Society and other organizations have discussed the importance of
informed decision making for men who are considering prostate cancer
screening, however this update is the first to provide details regarding
what information about screening is needed for informed decision-making
to occur,” said Alan G. Thorson, M.D., F.A.C.S., volunteer president of
the Society.
“For that reason, the updated ACS guidelines
delineate the core elements of information necessary for men to engage
meaningfully in this decision, and encourage inclusion of this
information in patient discussions and decision aids.”
“With these newly updated recommendations, the
American Cancer Society places even stronger emphasis on shared decision
making between clinicians and patients,” said Otis W. Brawley, M.D.,
chief medical officer of the American Cancer Society.
“The decision whether to screen should be made with
the help of a trusted source of regular care. Men without access to
regular care should not be tested unless high-quality informed
decision-making as well as appropriate counseling and follow-up care for
those who test positive can be assured. Without those, community-based
screening should not be initiated.”
American
Cancer Society
Difficulty determining who should be treated
Finding and treating prostate cancer early may seem like a
no-brainer, but the issue is actually very complicated.
Early prostate
cancer is typically found using a PSA test and a DRE. There are limits
to both methods, but the main issue is that even when these tests find a
cancer, they often can't tell how dangerous the cancer is.
Some prostate
cancers grow slowly and may never cause a man any problems, while others
are more aggressive. Treatments for prostate cancer can have a lot of
unpleasant side effects like incontinence and impotence that can really
affect the quality of a man's life.
Unfortunately, doctors can't be sure which men need treatment and
which would be fine without any. And men who are told they have prostate
cancer may have a hard time just doing nothing, even if the cancer is
unlikely to cause them harm.
Clearly, some prostate cancers would cause problems at some point.
For these men, screening and treatment is helpful. But often there's no
way to know what the outcome would have been in any particular man's
case without treatment.
The guidelines also includes updated clinical
recommendations regarding screening tests, intervals, and follow up of
abnormal results for those men who choose to be screened after
considering the possible benefits and risks.
The guidelines acknowledge the limited contribution
of digital rectal exam (DRE) to prostate cancer early detection and
state that screening can be performed using PSA with or without the DRE.
The guidelines recommend annual screening for men whose PSA level is 2.5
ng/ml or higher, but state that screening intervals can be safely
extended to every two years for men whose PSA is less than 2.5 ng/ml.
The guidelines affirm that a PSA level of 4.0 ng/ml
or higher remains a reasonable threshold to recommend referral for
further evaluation or biopsy for men at average risk of developing
prostate cancer; for PSA levels between 2.5 and 4.0 ng/ml, health care
providers should consider an individualized risk assessment that
incorporates other risk factors for prostate cancer in the referral
decision.
The update included a complete review of the
evidence
The American Cancer Society’s Prostate Cancer
Advisory Committee, composed of independent researchers, clinicians and
lay people, examined systematic reviews done by scientific experts at
Emory University, Rollins School of Public Health, met to hear
presentations by experts both on the Committee and by invited outside
experts, and deliberated the evidence before making its final
recommendations. The guideline underwent peer review before going before
the American Cancer Society volunteer Board of Directors for approval.
The authors conclude by noting the urgent need for
better ways to detect and treat early-stage prostate cancer,
particularly the need to distinguish between cancers that do not require
treatment and those that are aggressive, to help “tip the balance
clearly in favor of screening. Until that time, however, it will remain
incumbent on health care providers and the health care system as a whole
to provide men with the opportunity to decide whether they wish to
pursue early detection of prostate cancer.”
About the American Cancer Society
The American Cancer Society says it combines an
unyielding passion with nearly a century of experience to save lives and
end suffering from cancer. As a global grassroots force of more than
three million volunteers, we fight for every birthday threatened by
every cancer in every community. As the nation’s largest
non-governmental investor in cancer research, contributing about $3.4
billion, we turn what we know about cancer into what we do. As a result,
more than 11 million people in America who have had cancer and countless
more who have avoided it will be celebrating birthdays this year. To
learn more about us or to get help, call us any time, day or night, at
1-800-227-2345 or visit
cancer.org.
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