Recently, the American Urological Association (AUA) issued new guidelines on when men at average risk for prostate cancer should begin talking to their doctor about prostate-specific antigen (PSA) tests:
- No routine screenings for men at average risk, age 40-54 who have no concerning symptoms
- Routine screening for all men age 55-69
- No screening for men age 70 and older who have a life expectancy of less than 10 years (while recognizing that in some men over 70, there may be a benefit to routine screening)
These new guidelines generated a lot of media attention, as did the 2012 guidelines from the United States Preventive Services Taskforce (USPSTF). This group found the PSA test to be so unreliable that it saw no benefit to routinely screening healthy, symptom-free men of any age who were considered by their doctors to be at low risk. For both sets of guidelines, some of the media reports delivered a confusing message to the public.
mCancerPartner talked to John Wei, M.D., a urologist in the U-M Department of Urology who specializes in benign prostatic hyperplasia and prostate cancer detection, about making sense of these two sets of guidelines. Here is what Dr. Wei recommends as best practice for PSA screenings.
mCancer Partner: To begin, what is the short answer to this continuing question about who should get regular PSA screenings, and when?
Dr. Wei: I think it’s great that the AUA has renewed the conversation about who should be screened for prostate cancer. And since there has been a lot of dialog this spring, I’d like to make three important points to your readers.
- The AUA guidelines are just that, guidelines. They are not carved in stone. Men should feel free to ask their doctors for a screening PSA if they are concerned about prostate cancer. At the very least, this opens up a productive conversation about their personal risk for prostate cancer, and what to do about it.
- Patients and providers need to understand the difference between a ‘screening’ PSA and ‘diagnostic’ PSA. The screening use of PSA is, by definition, among asymptomatic men. Any man at any age who is showing symptoms of possible prostate cancer – blood in the urine, problems urinating, is receiving testosterone replacement or a 5 alpha reductase inhibitor, or has benign prostatic hyperplasia (bph) – should have a PSA test, but in these situations, it’s a diagnostic test, rather than a screening test.
- While I agree generally with the AUA about eliminating routine screening PSA tests for men 70 or older who have less than 10 years life expectancy, it really applies to anyone who has a life expectancy of 10 years or less.
mCancer Partner: Let’s talk about men 70 years and older. Would you automatically presume any man this age has a 10 year or less life expectancy?
Dr. Wei: No, and this helps to illustrate why the AUA guidelines should not be viewed as hard and fast rules. Years ago, the idea that men over 70 are likely to have less than 10 year life expectancy wasn’t that far off. But today, a lot of 70 year old men are expected to live well into their 80s and beyond, and some of these men live long enough to develop aggressive prostate cancer. Failure to diagnose aggressive prostate cancer in a vigorously healthy 71 year old may be worse than diagnosing low risk prostate cancer in a 61 year old with many life threatening health issues. By the same token, I wouldn’t advocate screening men of any age who have a life expectancy of less than ten years, if they have none of those signs of possible prostate cancer and are asymptomatic.
mCancer Partner: It sounds like communication is a very important component in the PSA screening process. What do you say to men who are younger than 54?
Dr. Wei: The AUA recommends that routine screening for men less than 54 should not be encouraged. I agree with that because the evidence for screening PSAs in this age group is very limited. It doesn’t mean that screening does is not beneficial for them but rather that there is no randomized clinical trial that clearly demonstrates the benefit of screening in this age range.
mCancer Partner: What about men with possible warning signs who say they don’t need the PSA test anymore?
Dr. Wei: There are patients in all these age groups who have an elevated risk for prostate cancer – perhaps as indicated by prior elevated PSA tests, prior prostate biopsy, or a strong family history of prostate cancer – who think PSA testing for them should be stopped because of the recommendations from the USPSTF. While the decision for PSA screening is ultimately up to the patient, I would explain to him what we know about PSA screening benefit and harms. If I think that the benefit of screening for him outweighs the risks of harms, then I would recommend that he continue PSA-based cancer screening. For example, a 50 year old man with an elevated PSA of 6 whose father succumbed to prostate cancer at age 55 should continue annual PSA screening as he has an elevated risk to develop a more aggressive form of prostate cancer.
The University of Michigan Department of Urology is consistently named one of the top 15 urology programs in the nation – a huge vote of confidence that our methods make a difference. Since 1920, we’ve provided comprehensive, compassionate care for adult and pediatric patients with urologic disorders. We are consistently recognized as one of the top clinical programs in the nation and the state by U.S. News and World Report. Our research program receives national recognition as well: we are one of the nation’s most highly funded urology research programs, according to the National Institutes of Health.
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