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Main Category: Prostate / Prostate Cancer
Also Included In: Urology / Nephrology;??Men?s Health;??Cancer / Oncology
Article Date: 21 Jul 2012 ? 9:00 PDT
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Doctors should discuss with their patients fully the risks and benefits of PSA prostate cancer screening if the patient has a life expectance of more than ten years, an ASCO (American Society of Clinical Oncology) Panel advised today in a new evidence-based PCO (provisional clinical opinion). The Opinion advises doctors whose patients have long life expectancies and have no signs or symptoms of prostate cancer to explain the pros and cons of prostate-specific antigen (PSA) testing. ASCO added that for men with shorter life expectancies, the screening risks are greater than the benefits.
The main benefit is detecting prostate cancer earlier on, when treatments tend to have superior results. The risks include unnecessary treatments (over-treatment) and their side-effects, over-diagnosis, and pointless biopsies.
ASCO?s PCO has been published in the Journal of Clinical Oncology.
ASCO?s guidance clashes with one issued by the US Preventive Services Task Force in May this year which recommends against PSA screening for prostate cancer.
Ethan Basch, MD, Co-Chair of the ASCO panel, said:
?For men with a shorter life expectancy, we agree that the risk of harms associated with PSA-based screening and subsequent unnecessary treatment likely outweigh the benefits.But for men with a longer life expectancy, our assessment of the evidence shows the balance of risks and benefits is less clear, and that well-informed conversations between men and their physicians remain worthwhile about harms, potential benefits, and appropriate management strategies if prostate cancer is found.?
ASCO has also issued a ?Detailed Decision Aid? aimed at helping doctors and their patients fully understand the benefits and potential harms of screening, so that they can better decide whether PSA testing is appropriate in a case-by-case basis.
Robert Nam, MD, ASCO panel Co-Chair, said:
?Our critical review of the evidence, including data on younger subpopulations of men, shows that PSA testing should not be discounted. We recognize that many want this debate settled, and want the answer to be clear-cut. But it isn?t. Until it is, we think physicians and men with longer life expectancies should be aware of the full scope of evidence on PSA testing for prostate cancer screening so they can make informed and shared decisions about the right course of action. Our goal is to help ensure that PSA testing is used intelligently and selectively, by testing and then treating only appropriate patients.?
Dr. Basch said:
?As the organization representing physicians who counsel and treat men with prostate cancer, we see the impact of screening and treatment decisions every day, and felt it was our responsibility to conduct a rigorous analysis of the available data to help guide this very important decision for many men. Our approach is a balanced one that takes into consideration the life expectancy of the patient as well as the values and preferences of individual men. We also advocate for the use of evidence-based decision aids, research to improve screening methods, and reduction of overtreatment of likely insignificant cancers ?
Below are highlights of the ASCO Panel?s recommendations:
- Patients whose life expectancies are ? 10 years ? the PSA screening for prostate cancer is not recommended. In these cases, the harms appear to outweigh the benefits.
- Patients whose life expectancies are ?10 years ? doctors should discuss fully the benefits and potential harms of PSA testing for prostate cancer to decide whether it is appropriate. PSA testing for men with long life expectancies has been shown to save lives. However, there are still risks of potential harms, including biopsy complications, pointless biopsies, and radiation treatments for a slowly-developing cancer that is usually not ultimately life threatening.
- The use of lay language ? in order to facilitate the discussions between patient and doctor, all data regarding the advantages and disadvantages of PSA screening for prostate cancer should be clearly laid out in lay language.
The ASCO Panel includes nine physicians with expertise in radiation oncology, uro-oncology, medical oncology, prevention and screening, and statistics. The Panel also includes a patient representative.
Why ASCO differed from the US Preventive Services Task Force
The ASCO Panel based its recommendations after looking at various sources, including the AHRQ analysis which was also reviewed by the US Preventive Services Task Force. ASCO says its panel considered updated, longer-term data from human studies and looked more carefully at data on a sub-population of younger males. Their recommendations differ with those issued by the US Preventive Services Task Force concerning patients with longer life expectancies.
The Panel says that overall, routine PSA-based screening does not appear to reduce prostate cancer mortality. However, they found that as far as men whose life-expectancies exceeded ten years, the evidence was not so clear.
In a sub-population study they reviewed, PSA testing might lower prostate cancer specific-mortality. They quoted the 11-year data from ERSPC (European Randomized Study of Screening for Prostate Cancer) which reported a 20% reduction in prostate cancer-specific mortality among 162,000 males aged 55 to 69 years.
The Panel?s PCO stressed that further compelling evidence regarding PSA testing for prostate cancer is urgently needed, especially data on high-risk subgroups, including men with a family history of the disease, and patients with an Afro-American ancestry.
More research is required on more accurate screening tests, include those which can help physicians determine which prostate cancers require treatment and which can be simply monitored for signs of progression.
The ?New Decision Aid? ? aimed at helping doctors and patients
The ?Detailed Decision Aid? is a tool that explains all available data and which considerations should be included regarding PSA testing. It is laid out in lay-terms and ?in a format men can use to discuss testing with their physicians.?
The aid is divided into two parts:
- Learning what the potential harms and benefits are with your doctor ? data from the ERSPC study are summarized, and include pictographs and clear explanations of the results. This trial is quoted because it is a very large, good-quality one.
- Helping patients think their decision through, on their own ? the patient is given a list of decision options regarding whether to do a PSA test.
Dr. Nam said:
?The best care starts with the best information. This decision aid will fill an important gap for men facing a decision about PSA testing, providing an starting point for this complex but worthwhile conversation.?
What did the US Preventive Services Task Force Panel say?
In May, 2012, the US Preventive Services Task Force Panel said that the harms of PSA-based testing for prostate cancer outweigh the benefits. Their recommendation, which was published in Annals of Internal Medicine, said that ?(PSA-based testing for prostate cancer) may benefit a small number of men but will result in harm to many others?. Their recommendation triggered a strong and sometimes angry response from many medical and patient groups.
The American Urological Association responded rapidly to the US Preventive Services Task Force Panel recommendation with the following statement:
?It is inappropriate and irresponsible to issue a blanket statement against PSA testing, particularly for at-risk populations, such as African American men. Men who are in good health and have more than a 10-15 year life expectancy should have the choice to be tested and not discouraged from doing so.?
Written by Christian Nordqvist
Copyright: Medical News Today
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