The harms of prostate-specific antigen (PSA) testing outweigh the benefits for men younger than age 50 years at average risk for prostate cancer, for men older than age 69 years, and for men with a life expectancy of less than 10 to 15 years, according to new recommendations from the American College of Physicians (ACP). The ACP therefore advises against screening for prostate cancer using PSA testing in these patients.
“Studies are ongoing, so we can expect to learn more about the benefits and harms of screening, and recommendations may change over time,” commented ACP president David L. Bronson, MD, in a statement issued by the organization.
For now, however, “Screening for Prostate Cancer: A Guidance Statement from the Clinical Guidelines Committee of the American College of Physicians,” published along with a summary for patients in Annals of Internal Medicine, sets forth the ACP recommendation that clinicians inform men aged 50 to 69 years about “the limited potential benefits and substantial harms of screening for prostate cancer.”
One harm associated with prostate cancer screening includes misinterpretation of test results. For example, a high PSA reading may indicate not cancer but an an enlarged prostate; conversely, a man may have a low PSA value even though cancer is, in fact, present. According to the ACP guidance, the false-positive rate for PSA levels greater than 4.0 is 70%.
A positive PSA test can lead to prostate biopsy, which itself may result in such problems as infection or significant bleeding. When prostate cancer is discovered and the decision to undergo treatment is made, therapy can cause erectile dysfunction and urinary incontinence. However, the cancer may never have become clinically evident in the man’s lifetime, rendering treatment and these side effects unnecessary, asserts the ACP in its guidelines.
The ACP advises that clinicians base the decision to screen for prostate cancer using the PSA test on the patient’s risk for prostate cancer, a discussion of the benefits and harms of screening, the patient’s general health and life expectancy, and patient preferences. Clinicians should not screen for prostate cancer using the PSA test unless a patient expresses a clear preference for screening, states the ACP.
As noted in the ACP guidance, the United States Preventive Services Task Force concluded in its 2012 guideline that the harms of prostate cancer screening outweigh the benefits for most men. The American College of Preventive Medicine (ACPM), the American Cancer Society (ACS), and the American Urological Association (AUA) all found in their most recent reviews (2008 for ACPM, 2010 for ACS, and 2009 for AUA) that it is uncertain whether the benefits of routine screening using the PSA test outweigh the harms. All three organizations advocate use of a shared decision-making approach, but the recommendations regarding shared decision-making vary among the groups.