PSA Testing: Have We Learned From Our Errors?


I am Dr. Gerald Chodak for Medscape. In May 2013, the American Urological Association (AUA) issued a new set of guidelines for recommendations regarding screening for prostate cancer. Many people will applaud these changes because they are more in line with evidence-based findings from randomized trials.

Essentially, the guidelines say the following: They recommend against screening men under age 40. They do not encourage routine screening of men between the ages of 40 and 54 years, men over age 70, and men with a 10- to 15-year life expectancy. They do acknowledge that some men over age 70 could benefit.

The guidelines encourage the core group of men between ages 55 and 69 years to have a discussion with their healthcare provider about the pros and cons, the risks and the benefits, of screening, including that during 10 years of follow-up, studies have shown that 1 life is saved for every 1000 men who are screened. They acknowledge that, in large groups of men, this could translate into a significant benefit, particularly with longer follow-up.

Where does this leave us? The message is somewhat confusing, because for men aged 40 to 54 years or over age 70, the wording "does not encourage screening" presents a bit of a dilemma. When the patient asks, "Are you telling me that you recommend against screening?" the healthcare provider will say, "No, the statement doesn't say that. We are just not encouraging you to have screening." To me, that is a mixed message. If you are not encouraging screening, then you must believe that it is not clearly of benefit. What is the difference between that and telling them that you do not recommend screening? I think the guidelines need to have more clarity on this; otherwise, patients are going to find themselves confused.

Another issue brought up by the AUA is the possibility of reducing the harms of screening and the harms of treatment by changing the frequency of screening from every year to every 2 years for men with average risk. This may cut down on the detection rate somewhat and reduce the overdiagnosis rate.

But what should we do for high-risk men? Do we tell them that they should continue to be aggressively tested even though we have no data to prove that this will save their lives?