Doctors disagree on when to stop PSA screening

NEW YORK Mon May 28, 2012 11:07am EDT

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NEW YORK (Reuters Health) - Doctors vary when it comes to deciding when an older man can stop routine PSA screening for prostate cancer, a new study finds.

In the U.S., many men now have their cancer diagnosed at an early stage through screening with prostate-specific antigen (PSA) blood tests.

Although that sounds like a good thing, PSA screening is controversial. On Monday, the U.S. Preventive Services Task Force (USPSTF) -- an expert panel advising the federal government -- recommended against routine screening for men at average risk of prostate cancer, regardless of their age (see Reuters story of May 21, 2012).

That's because prostate cancer is often slow-growing and may never progress far enough to threaten a man's life. So finding and treating early tumors can do more harm than good for some men, since treatment carries risks.

For elderly men in particular, the risks of surgery or other treatments are usually thought to outweigh any potential benefit. On top of that, a man's PSA levels often rise with age, or because of benign prostate enlargement -- so an elevated PSA level may lead to unnecessary biopsies.

For those reasons, the USPSTF has long recommended against routinely doing PSA screening in men age 75 and older.

But some other groups, including the American Cancer Society, have more liberal guidelines. Their recommendations say doctors should consider a man's age and his life expectancy -- because if an elderly man is healthy and could live for another decade or more, he might still benefit from PSA screening.

In the new study, researchers at Johns Hopkins School of Medicine in Baltimore looked at how primary care doctors in their university network typically handle the age question.

They found, not surprisingly, that practices varied. Of 125 doctors, about one-third said they had no particular age when they stopped recommending PSA screening.

Of the rest of the group, a little more than half stopped routinely screening patients at the age of 75, compared to 21 percent who stopped at age 80 or older and 27 percent at age 70 or younger.

When asked about the obstacles to stopping PSA screening, three-quarters of doctors said their patients "expect" to continue getting yearly PSA tests.

It's not fully clear how much of a barrier patients' expectations are, according to Dr. Craig E. Pollack, the lead researcher on the study.

"If you ask patients about screening, they'll often say they rely on their doctors' recommendations," Pollack said.

The message for older men, according to Pollack, is to have an open discussion with your doctor about whether it's time to stop PSA screening.

But the decision can be tricky. In this study, 59 percent of doctors said they take a man's age and life expectancy into account -- as recommended by the American Cancer Society and the American Urological Association.

But estimating life expectancy is tough, Pollack said. Two-thirds of doctors in the survey said it was "somewhat" to "very" difficult.

Going forward, Pollack said, it will be important to develop better "decision support" tools to help primary care doctors estimate men's life expectancy, and then discuss with their patients how life expectancy fits into PSA screening.

Of course, experts disagree about whether most men should even start PSA screening in the first place.

When the USPSTF came out with its recommendations Monday, critics charged that the advice will cost lives.

Supporters, though, said that stopping routine screening would prevent needless cases of incontinence and erectile dysfunction that can come from prostate cancer treatment.

And they pointed out that the task force advice does not mean men cannot have PSA screening -- but that they should decide with their own doctors what's best for them.

Exactly what impact the new USPSTF recommendations will have is unclear. A study published last month found that although the task force has long advised against PSA screening for men age 75 and up, doctors often do it anyway (see Reuters Health story of April 26, 2012).

Of nearly 15,000 elderly men surveyed in 2010, 60 percent said they'd had a PSA test in the past year.

And another study, published in the Journal of the American Medical Association, found that the percentage of older men getting PSA screening did not change after the USPSTF recommendation was published in 2008 (see Reuters Health story of April 25, 2012).

Before and after the guidelines came out, about 44 percent of older men said they'd had a PSA test recently.

Just over 28,000 U.S. men will die of prostate cancer this year, according to the American Cancer Society. But close to 242,000 new cases will be diagnosed.

According to the National Cancer Institute, about half of all U.S. men diagnosed with prostate cancer in 2009 fell into the "low-risk" category -- meaning their cancer was unlikely to progress.

SOURCE: Cancer, online April 19, 2012.

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Comments (3)
explorer08 wrote:
Any man over 50 who stops regular PSA screening is an absolute fool. Men, do NOT pay attention to those who say it is OK to stop – - it is not OK to stop screening. What matters is not any particular PSA score in a given year but, rather, what is known as PSA Velocity – - the rate at which your PSA changes year over year. My PSA numbers were always fairly low, well below 4.0 (the supposed number under which popular opinion says you are OK). My highest PSA was 4.4 at age 63. However, my PSA went from 3.0 to 4.4 in 20 months. My post-prostatectomy Gleason score was 9!! So, it is very clear I had aggressive prostate cancer even when my PSA numbers were well below 4.0. Thank God I had done annual PSA screening. I’d probably have metastasized cancer by now if I had not. So, take it from me, do NOT stop annual PSA screening. You can make careful decisions based on the numbers but without those numbers you’ll have no basis for any decision making.

May 28, 2012 11:44am EDT  --  Report as abuse
ugg wrote:
If men quit using cough syrup, they will have no problem peeing. Drink clean water from various places and eat all natural foods. Caution eating in restaurants, you could be consuming bug spray, tainted oils, outdated food products. All these same thing could plague you at home if you neglect to stay on top of things. The organs are sensitive to toxic material from everywnere, not to mention that April 20,2012 they closed down the 2nd Nuclear Reactor at San Onofre because of it putting out toxic steam. If your home faucet water reads 500 or more parts per million, maybe you should not be putting any of it in your body.

May 28, 2012 1:30pm EDT  --  Report as abuse
SuefromSault wrote:
The usual argument. Better put like this:
Some men care more about the fear of cancer than they do about the embarrassment of wetting the bed or the loss of their sex life. They should get PSA tests and prostate biopsies.
Some men really do not want a sex life and having their prostate removed solves the problem. They should get PSA tests and prostate biopsies.
Some men like sex better than food and they should stop getting PSA tests when they feel like it.
AND SOME DOCTORS make a lot of money by referring their patents for biopsies. Guys who like sex should avoid these doctors!

May 29, 2012 2:05pm EDT  --  Report as abuse
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