Urology group stops recommending routine PSA screening for men

A large physicians group representing urologists who treat prostate cancer has stopped recommending a routine blood test to screen for prostate cancer, saying that men should decide with their doctors whether to be screened for the prostate specific antigen marker.

This puts the urologists in line with recommendations against routine PSA screening issued nearly a year ago by a government task force comprised of primary care providers.

While the American Urological Association once recommended that all men over age 50 have a yearly PSA test, the new guidelines state that PSA screening isn’t recommended for men at average risk under age 54 or over age 70. Those ages 55 to 60 “should now speak with their physician about the benefits and harms of testing to determine the best course of action,” according to the new guidelines released Friday morning at the urology group’s meeting in San Diego.

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In 2009, the urology group lowered their recommended age for PSA screening, saying that all men should get a baseline blood test at age 40 and that those with a family history or any signs of the marker should go on to have regular screening. All men over age 50 were told to have yearly PSA screens as well as digital rectal exams to check for prostate growths.

“This new guideline has been in the works for two years, well before the (government) task force released their recommendation,” said Dr. H. Ballentine Carter, director of adult urology at the Johns Hopkins School of Medicine and leader of the group that wrote the new recommendations. “It’s based on evidence from clinical trials.”

The previous recommendations, he added, were based on what urologists considered the “best practice” of medicine based on their own clinical experience—including treating men who died from prostate cancers that were detected too late to be cured.

While many urologists strenuously objected to the primary care task force recommendations issued last year, many may be more willing to embrace their own group’s guidelines, which emphasize shared decision-making between the doctor and patient to determine whether a PSA test should be performed.

The task force recommended against screening—and told doctors not to offer it to patients—but also instructed physicians to perform it on any man who asked for it.

“What we’re seeing now is some harmonization of the various guidelines,” said Dr. Michael Barry, president of the Informed Medical Decisions Foundation, who co-authored the urology group’s recommendations. “No one is recommending automatic testing of anyone anymore.”

Men younger than age 55 years who are deemed to be at higher risk of prostate cancer—because they are African American or have first-degree relatives who died of prostate cancer—should talk to their doctors about their risks and weigh them into their decision about whether to have PSA screening, according to the urology group guidelines.

But PSA screening should no longer be the default option during a yearly physical that men need to opt out of, Barry added. “If an informed man wants to be screened knowing what he’s getting into, then that should be reasonable.”

Based on clinical trials conducted in Europe, screening 1,000 men with a yearly PSA test over 10 years will result in the prevention of one death from prostate cancer. But to prevent that one death, 55 men will have biopsies that turn out not to be cancerous, while others will be treated for cancers that leave permanent side effects like urinary incontinence or impotence.

The latest data suggests that about half of prostate cancers are overdiagnosed, meaning they would never have become life threatening if left undetected and untreated.

While most men should be having informed discussions about the risks and benefits of PSA screening with their primary care physicians, some of these physicians may have already decided against offering screening to patients.

“Primary care physicians tend to look at the task force guidelines, and these new ones won’t have any impact if they don’t use them,” said Dr. Anthony D’Amico, chief of genitourinary radiation oncology at Brigham and Women’s Hospital. He said he conducted a poll of several thousand primary care physicians at a meeting this past February, asking them who was still offering PSA testing. About 50 percent said they were, compared with 80 percent a year earlier before the task force guidelines came out.

“I think the pendulum is shifting toward screening high-risk patients and looking for more aggressive disease, which is good,” D’Amico said. “But there are pitfalls here” if PSA testing stops all together. “I think we may see a rise in prostate cancer deaths by 2020.”