Doctors Get Guidance on Discussing PSA Test

A medical group has advice for primary care doctors about how to discuss prostate-cancer screening with patients. The new statement comes from the American College of Physicians, the group for doctors of internal medicine. It is based on guidelines from several organizations. The statement applies to male patients between ages 50 and 69. Doctors should talk with them about the risks and benefits of prostate-specific antigen (PSA) testing, the statement says. PSA tests are used as a first screening test for prostate cancer. But a biopsy is needed to find out if cancer exists. Most prostate cancers grow very slowly and cause no harm. However, no known tests can tell which cancers will be deadly. Treatments can cause harmful side effects. The journal Annals of Internal Medicine published the study online April 8. HealthDay News wrote about it.

By Lori Wiviott Tishler, M.D.
Harvard Medical School

What Is the Doctor's Reaction?

Today, I am writing about a complicated aspect of men's health, the PSA test for prostate cancer screening. This new journal article addresses an important question, "Should we test for prostate cancer in men between the ages of 50 and 69, just because we can?"

In my practice, most men, when given the choice, opt for prostate-specific antigen (PSA) screening. Many of my patients feel that it is better to do something than to do nothing. This new article reviews numerous guidelines about PSA testing from different medical groups. It also makes some helpful suggestions about how doctors and patients should think about and discuss the PSA screen for prostate cancer.

A good screening test should help us find an undiagnosed condition for which effective treatment exists. Treating that condition should lead to a better outcome.

So the question about PSA screening is whether we can say that it saves lives, as mammograms do for women ages 50 through 75. Can we say that early treatment of prostate cancer makes men live longer, healthier, happier, disease-free lives?

Unfortunately, the answer to the above question for PSA screening is no. That makes it difficult to give advice to men who would rather do something than do nothing. It's hard for American doctors to tell American patients that nothing is better.

The article recommends something called "shared decision making." It suggests that men should be closely informed of the following 10 complicated ideas:

• The PSA is a controversial test.
• The risks of the test outweigh the benefits.
• Most men with prostate cancer do not die of prostate cancer.
• Most men who do not get a PSA test will die of something other than prostate cancer.
• Men who choose a PSA test are more likely to be diagnosed with prostate cancer.
• A high PSA, in most cases, cannot tell us if the prostate cancer is a fast-growing cancer or a slow-growing cancer.
• Testing may prevent 1 death for every 1,000 men tested over an 11-year period.
• There are many harms of screening, including the risks of surgery and radiation treatment.
• Every man should have the chance to decide for himself about whether or not to have the test.
• Men can change their minds at any time. Doctors should tell patients that we may learn more from the science and that doctors' advice may also change over time.

That's a big message. It's not hard to understand, and the underlying advice to patients is: "Don't opt for the test." The underlying advice to doctors is: "Don't do the test unless the patient understands the points above and has a very clear preference for it."

As a primary care doctor, I agree with this message. However, I am also aware that in a busy medical office, it's really hard to find the time to ensure that the patient understands all of these important issues. It's easier for doctor and patient to check off a lab test than to review this message. So, as we rethink our message, doctors also will need to rethink how we deliver that message.

What Changes Can I Make Now?

If you are a man between the ages of 50 and 69, try to learn about the risks and benefits of prostate cancer testing. Then talk to your doctor about your level of risk and whether or not testing is worthwhile for you.

If you are younger than 50 or older than 69, probably you should not be tested for prostate cancer using the PSA test.

If you are a man with a strong family history of prostate cancer or an African-American man, start the discussion about the benefits and risks of testing when you are 40 to 45.

For men and women, the controversy about the PSA test is a great reminder to be informed about choices in health care and how to evaluate risks and testing.

What Can I Expect Looking to the Future?

I have two hopes for PSA testing and screening in general. First, I hope that we develop a better test. I hope we can find a test that helps us know which men might have aggressive cancers, so we can treat them, cure them and save lives.

Second, as I think about the complicated discussions above, I also hope that doctors will find more effective ways to share information with patients. This could occur through conversations with doctors or other clinical staff, or using old and new media. Better communication will enhance the lives of patients and the quality of work life for doctors.