Urology Group: Prostate Screening Should Be Offered Beginning at Age 40

Chicago—The controversy swirling around the appropriateness of screening for prostate cancer may have become even more controversial.

At the annual meeting of the American Urological Association (AUA), held here in April, the association released an updated “best practice” statement that calls for offering early detection of and risk assessment for prostate cancer to all asymptomatic men at age 40 years with an estimated life expectancy of more than 10 years. This process would involve determining a baseline prostate-specific antigen (PSA) level to help physicians and patients develop a strategy for monitoring prostate cancer risk. Depending on the baseline reading, such a strategy might involve annual PSA testing and digital rectal examination (DRE) or more infrequent testing (http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/psa09.pdf).

However, the AUA's new guideline is at odds with the policy of the American Cancer Society (ACS), which recommends annual prostate cancer screening with PSA testing and DRE beginning at age 50 years—if the physician discusses the risks and benefits of such testing and the patient agrees to be screened. And both the AUA and ACS recommendations disagree with those of the American Academy of Family Physicians and the US Preventive Services Task Force, which state that evidence is lacking to make a recommendation for or against prostate cancer screening for the general population (the task force adds that screening is unlikely to benefit men older than 75 years). The American College of Physicians does not have guidelines for prostate cancer screening and refers physicians to the task force's recommendations.

Otis W. Brawley, MD, chief medical officer of the ACS, said much of the AUA's 82-page statement made sense, but he could not understand the rationale for establishing baseline PSA levels in 40-year-old men. “The truth be told, I was shocked when I read that,” Brawley said. “That [age point] comes from the results of 2 studies. But those looked at diagnosing prostate cancer and the entire cancer care community should be moving away from how to diagnose prostate cancer to how to determine which cancers kill and which cancers don't kill.”

The conundrum facing patients and physicians is that prostate cancer is slow-growing and may take years before causing adverse effects. The ACS estimates that in 2009 there will be 192 280 new cases of prostate cancer in the United States and 27 360 men will die. Because detection of prostate cancer does not allow physicians to clearly determine which cancers are aggressive and worrisome, the result is overtreatment that can leave patients who would not have died of the disease with complications such as impotence, incontinence, and anxiety.

Peter R. Carroll, MD, MPH, chair of the AUA panel that issued the best practice statement and chair of the Department of Urology at the University of California, San Francisco, said the panel updated the 2000 guideline because studies over the past few years have shown that men as young as age 40 years with PSA levels above the age-appropriate median are at greater risk of developing prostate cancer (Loeb S et al. Urology. 2006;67[2]:316-320) and that screening can reduce mortality rates by 20% (Schröder FH et al. N Engl J Med. 2009;360[13]:1320-1328).

“Part of our rationale is that younger men are more likely to have curable cancers and the PSA is a more specific test in this population,” Carroll said. “We also think earlier and less frequent testing based on a man having a lower than median PSA level might reduce health care costs.”

In addition to lowering the age for determining a baseline PSA level, the best practice statement no longer recommends a single threshold value of PSA that prompts biopsy to confirm the presence of cancer. It notes that multiple factors, such as free and total PSA, patient age, PSA velocity (the rate at which the number increases) and density, family history, ethnicity, prior biopsy history, and comorbidities, should be taken into account.

Carroll added that the 40-year baseline recommendation does not exist in a vacuum and that physicians should have explicit discussions with their patients about both the benefits of early detection and the risks of overtreatment. To help promote such discussions between physician and patient, Brawley said, the ACS is developing a 1-page document aimed at patients, written at an eighth-grade level, that will make clear the benefits and risks of screening for prostate cancer.