ACS updates prostate cancer screening guidelines

Recommendations confirm the importance of shared decision making

Newly updated prostate cancer screening guidelines from the American Cancer Society reaffirm the recommendation that men should discuss the uncertainties, risks and potential benefits of screening for prostate cancer before deciding whether to be tested.

The recommendations, last updated in 2001, included systematic reviews of 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 guidelines were published online last week in advance of publication in CA: A Cancer Journal for Clinicians. Dr. Ruth Etzioni of the Public Health Sciences Division was on the 12-member panel that helped revise the guidelines.

The peer-reviewed recommendations include:

  • Asymptomatic men who have at least a 10-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 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.
  • Asymptomatic men who have less than a 10-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.

“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,” said Dr. Andrew Wolf, associate professor of medicine at the University of Virginia Health System and chair of the Advisory Committee. “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.”

The guidelines also include updated clinical recommendations regarding screening tests, intervals, and follow up of abnormal results for those men who choose to be screened. The guidelines acknowledge the limited contribution of digital rectal exam to prostate cancer early detection and state that screening can be performed using PSA with or without the digital exam. 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 panel noted 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.”

[Adapted from an American Cancer Society news release.]

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