Prostate Cancer Screening Guideline Updated by ACS

Nick Mulcahy

March 03, 2010

March 3, 2010 — For the first time since 2001, the American Cancer Society (ACS) has updated its prostate cancer screening guideline.

The new guideline has a more pronounced emphasis on informed decision-making (IDM) than in the past.

We are making a stronger case for informed decision-making.

Men should only be screened "after they receive information about the uncertainties, risks, and potential benefits associated with prostate cancer screening," states the document.

"We are making a stronger case for informed decision-making," lead author of the guideline, Andrew Wolf, MD, told Medscape Oncology.

"We have explicitly outlined in this guideline what we feel to be the core elements [that need] to be imparted to patients for an informed decision to occur," said Dr. Wolf, who is associate professor of medicine at the University of Virginia School of Medicine in Charlottesville.

Dr. Wolf also explained that "decision aids," or educational tools tailored to patients, are vital to the practicality of the recommendation for IDM.

There are also several new recommendations for men who choose to be tested.

Prostate-specific antigen (PSA) testing is now recommended with or without the digital rectal exam (DRE). "There is little evidence that the digital rectal exam adds significant benefit to the PSA test, except, perhaps, when the PSA is in the borderline range," he said.

The ACS continues to recommend that the PSA value of 4.0 ng/mL be used as a "reasonable threshold" to trigger further evaluation, said Dr. Wolf.

However, there is a new recommendation for men with PSA values between 2.5 and 4.0 ng/mL.

"Recognizing that approximately 25% of men with PSA levels between 2.5 and 4.0 ng/mL harbor prostate cancer, we have added a recommendation that physicians consider an individualized risk assessment for men with PSA values in this indeterminate range," said Dr. Wolf.

An individual assessment should take into account non-PSA risk factors, such as race, family history, results of previous biopsies, and DRE results, he said

ACS also now recommends that the PSA testing interval be reduced to every other year for men whose PSA level is under 2.5 ng/mL. "Such a reduction in testing frequency will lead to significantly reduced false positives, unnecessary biopsies, and overdiagnosis, with only a negligible increase in missed cancers," explained Dr. Wolf.

The American Urological Association (AUA) differs with the ACS on PSA values. "The AUA feels there is no single PSA standard that applies to all men, nor should there be," they write in a press release issued soon after the guideline was made public this week.

"Although prostate cancer risk correlates with serum PSA, there is no PSA value below which a man may be reassured that he does not have biopsy-detectable prostate cancer," the AUA press release adds. The AUA also advocates for a baseline PSA test at the age of 40, and subsequent rescreening that evaluates, among other risk factors, free and total PSA, PSA velocity, and PSA density.

Overall, clinicians will recognize much of the old ACS guideline in the new document, which was published online March 3 in CA: A Cancer Journal for Clinicians.

"The 2010 guideline does not represent a substantive departure from our 2001 guideline," said Dr. Wolf.

Decision Aids to the Rescue

In the context of prostate cancer screening, IDM and shared decision-making (SDM) is no small job, the guideline suggests.

"The challenge of offering every eligible man the opportunity to make an informed decision about prostate cancer screening can be daunting to the healthcare provider," write Dr. Wolf and his coauthors.

Time constraints and the "complexity of the issue" are the "key obstacles" to IDM/SDM, according to healthcare providers, the authors note.

In addition, there is no reimbursement for IDM/SDM.

Dr. Wolfe acknowledged the problem of lack of reimbursement.

I am not aware of any specific reimbursement for counseling related to prostate cancer early detection.

"Primary care physicians can be reimbursed for counseling time if it comprises more than half of the office visit and is documented. However, I am not aware of any specific reimbursement for counseling related to prostate cancer early detection," he said.

The time and money problems related to IDM/SDM are not insurmountable, suggested Dr. Wolf.

"This is a vital point that we tackled head on with this revised guideline," he said about these practical challenges.

"Recognizing that insufficient time is cited by physicians as the greatest barrier to engaging men in informed and shared decision-making related to prostate cancer, the American Cancer Society guideline strongly advocates the use of decision aids," he declared.

Decision aids should be given to patients before an office visit, suggested another expert.

"By providing a decision aid in advance of a clinic visit, the patient–provider discussion — the shared decision-making — can be much more efficient, addressing screening decisions in the context of a patient's specific medical conditions, values, and concerns," said Richard Hoffman, MD, MPH, an internist at the Raymond G. Murphy VA Medical Center in Albuquerque, New Mexico, who has studied doctor–patient communication surrounding PSA testing. Dr. Hoffman was approached for independent comment by Medscape Oncology.

Healthcare dollars might be also be saved, he suggested.

Decision aids potentially could reduce healthcare costs.

"Often, informed patients make more conservative treatment decisions, so decision aids potentially could reduce healthcare costs," said Dr. Hoffman

In the state of Washington, legislation has been passed supporting the use of various decision aids and implementing demonstration projects, noted Dr. Hoffman.

Dr. Wolf agrees that the decision aids have multiple benefits.

"Decision aids lead to improved knowledge, decreased "decisional conflict," and a greater desire to play an active role in the decision," he said, referring to clinical studies.

Exactly how clinicians should use decision aids remains to be seen, explained Dr. Wolf.

"Physicians will still need to figure out how to incorporate decision aids into their own practices," he said.

Problems remain as well. "There are still obstacles to address: we need more decision aids that are tailored to low-literacy and non-English-speaking populations," Dr. Wolf noted.

Still, the new guideline is unequivocal about the need for doctor–patient discussion.

"No man should be tested without having first engaged in an informed decision-making process," summarized Dr. Wolf.

The ACS guideline document includes links to the decision aid materials of different organizations, including the ACS, the Foundation for Informed Medical Decision Making, the Centers for Disease Control and Prevention, the Mayo Clinic, and the University of Cardiff in the United Kingdom.

Informed Decision-Making: By Age and Core Elements

At the age of 50, men at average risk for prostate cancer should start receiving facts about prostate cancer and screening, states the new ACS guideline. 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 information beginning at age 40.

The "core elements" of the information to be provided to men to assist with their prostate cancer screening decision include the following:

  • Screening with the PSA blood test detects cancer at an earlier stage than if no screening is performed.

  • Prostate cancer screening might be associated with a reduction in the risk of dying from prostate cancer; however, evidence is conflicting.

  • For men whose prostate cancer is detected by screening, it is not currently possible to predict which men are likely to benefit from treatment.

  • Treatment for prostate cancer can lead to urinary, bowel, sexual, and other health problems that can be significant or minimal, permanent or temporary.

  • The PSA and DRE can produce false-positive or false-negative results.

  • Abnormal results from screening with PSA and DRE require prostate biopsies, which can be painful and lead to complications like infection or bleeding.

  • Not all men whose prostate cancer is detected through screening require immediate treatment. Some require periodic blood tests and prostate biopsies to determine the need for future treatment.

Dr. Hoffman reports receiving partial salary support from the nonprofit Foundation for Informed Medical Decision Making to help develop a prostate cancer screening decision aid.

CA Cancer J Clin. Published online March 3, 2010.

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