The American Cancer Society (ACS) recently announced their “updated” 2010 guidelines for prostate cancer screening in men.1 Once again, with the announcement of these guidelines, there were countless articles and opinion pieces on the controversy over screening, detection and treatment of the most common solid tumor in men.
The centerpiece of this latest ACS prostate cancer article was the concept of “shared decision making” whereby the patients and the provider discuss the relative risks and benefits of screening. The authors reaffirmed this core concept that the American Cancer Society had noted in their 2001 prostate cancer screening guidelines.
The 2010 ACS discussion of shared decision making is not a new or unique idea. The American Medical Association Council on Scientific Affairs reviewed the medical/scientific literature on the topic of prostate cancer screening in June 2000. The AMA reported that as far back as the 1990’s organizations such as the American College of Radiology, the American College of Physicians, and the American College of Preventive Medicine endorsed the concept of informed discussions with the patient or listening to the patient’s concerns and then individualizing the decision.
While not perfect, the PSA blood test represents our most powerful resource in the early detection of prostate cancer. The Prostate Cancer Prevention Trial demonstrated that there is no lower level of PSA that absolutely predicts the presence or absence of prostate cancer. Growing data suggests that PSA increases, especially in younger men, suggests an increased prostate cancer risk. Until a better test comes along, experiences gained from clinical trials and large institutional series are teaching us how best to use PSA in screening and biopsy decisions.
Last year, the American Urological Association who also affirmed the need for shared decision making, took a bold step in recommending a baseline PSA determination at age 40. The principle is to identify those men who should be screened more frequently and may identify men who harbor lethal prostate cancer. Early detection through PSA testing may reduce the mortality from the disease and PSA based screening is often cited one of the reasons for the observed fall in prostate cancer mortality in the US. The concept that PSA testing can reduce the likelihood of dying from prostate cancer but at the risk of over treatment of some men is acknowledged by many groups including the ACS in their 2010 guidelines.
A controversial issue is that screening may lead to over diagnosis and over treatment of clinically insignificant cancer that will never cause any harm. A more sinister and poorly documented issue in the medical literature is the threat of malpractice. Providers on the front lines are at risk for “failure to diagnose” prostate cancer by not promoting screening. Both of these concepts are dependent on the quality of the patient physician relationship. Patients must realize if screening leads to the diagnosis of prostate cancer, treatment may not be recommended. If the patients elects treatment, the disease may or may not be cured or the patient may suffer treatment related side effects. A reluctance on the part of the patient or his physician not to screen can result in the “failure to diagnose” debacle. The burden here seems to be shared by both the patient and the physician who can each suffer unique risks when venturing into the unsettled area of prostate cancer screening.
According to one popular definition, the term “reloaded” means “to refresh a copy of a program in memory”. The American Cancer Society has “reloaded” the topic of prostate cancer screening. They have refreshed our memory that a discussion between the patient and provider about the risks and benefits must be a part of the prostate cancer screening decision.
1. Wolf AM, Wender RC, Etzioni RB, Thompson IM, D’Amico AV, Volk RJ, Brooks DD, Dash C, Guessous I, Andrews K, DeSantis C, Smith RA; American Cancer Society Prostate Cancer Advisory Committee. American Cancer Society guideline for the early detection of prostate cancer: update 2010. CA Cancer J Clin 2010;60(2):70-98.
© The Canadian Journal of Urology™; 17(2); April 2010