April 19, 2013
The American College of Physicians Releases Prostate Screening Guidelines
My regular readers have been following the controversy about prostate cancer screening for some time. The controversy boils down to the following question. Should healthy men be routinely tested for prostate cancer? The most recent chapter in the controversy was written last year when the US Preventive Services Task Force (USPSTF) recommended against prostate cancer screening for men of any age. If this is news to you, or sounds absolutely preposterous, follow the previous link to read about the rationale of the USPSTF recommendation. The bottom line is that the benefits of screening have been shown to be very small or nonexistent, while the harms are proven and significant.
But where does that leave physicians? If you’re a man between 50 and 70 and you've seen me for an annual exam in the last year, you know that the recommendations have led to very difficult discussions without very clear guidance. Many men are used to annual screening and are distressed at the idea that suddenly we would do nothing to detect a potential cancer. Younger healthier men are especially puzzled about what to do since they would be most likely to die from an undiagnosed prostate cancer, though they would be least likely to develop prostate cancer.
To clarify our current understanding, and provide direction that is somewhat more useful to primary care physicians, last week the American College of Physicians released guidance statements that crystallize their recommendations.
Guidance Statement 1: ACP recommends that clinicians inform men between the age of 50 and 69 years about the limited potential benefits and substantial harms of screening for prostate cancer. ACP recommends that clinicians base the decision to screen for prostate cancer using the prostate-specific antigen test on the risk for prostate cancer, a discussion of the benefits and harms of screening, the patient's general health and life expectancy, and patient preferences. ACP recommends that clinicians should not screen for prostate cancer using the prostate-specific antigen test in patients who do not express a clear preference for screening.
Guidance Statement 2: ACP recommends that clinicians should not screen for prostate cancer using the prostate-specific antigen test in average-risk men under the age of 50 years, men over the age of 69 years, or men with a life expectancy of less than 10 to 15 years.
I find this very helpful, and it will help guide my conversations with men who are 50 to 69. It incorporates our current understanding while acknowledging that patients have unique values, anxieties, and preferences that should inform their care. If you’re a man between 50 and 69 give Guidance Statement 1 a close reading and tell your doctor what you think. If you love a man of that age, send him this post.
Screening for Prostate Cancer: A Guidance Statement From the Clinical Guidelines Committee of the American College of Physicians (Annals of Internal Medicine)
Some of my previous posts about prostate cancer:
The images and stories from Boston are terrifying and heartbreaking. I believe there is a fascinating story to be written about the medical aspects of the minutes, hours, and days after the explosions. I hope we eventually read that story. By all accounts the first responders, the emergency department staffs, and the surgical teams did extraordinary work very quickly. The newspaper stories suggest that many of the wounded have survived life-threatening injuries because of the fast and organized work of many dedicated professionals. I know that all of you join me in wishing physical and emotional recovery to the injured, calm and focus to the medical teams, and deep condolences to the bereaved.
This Sunday is Ciclavia, a citywide event in which 15 miles of streets are closed to traffic and open for strolling, biking, and exploring the city. It’s a perfect opportunity to demonstrate that we will still gather in large groups, have fun, get some exercise, and wear Red Sox hats.
Important legal mumbo jumbo: