Men who undergo prostate-cancer screening should discuss with a doctor the uncertainties, risks and benefits of the test before it is performed, says Edward Partridge, M.D., president-elect of the American Cancer Society (ACS) National Board of Directors and director of the University of Alabama at Birmingham (UAB) Comprehensive Cancer Center.
"We reaffirm the importance of informed and shared decision-making between a man and his doctor regarding prostate screening," Partridge says. "We want people talking openly and honestly with a health-care provider about the pros and cons of these tests to be in a better position to understand the results."
His comments came after the ACS issued updated screening guidelines that suggest doctors more actively involve patients in the decision of whether or not to be screened for prostate cancer. While not a radical change from the previous prostate-screening recommendations, the new guidelines offer clearer guidance on those things that should be discussed, says Partridge, a co-investigator on the national Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO trial) that helped inform the updated guidelines.
Erik Busby, M.D., an assistant professor in the UAB Division of Urology, seconded Partridge. "The bottom line is that physicians need to inform men of the benefits of screening before performing it, and the decision should be made with a trusted source of regular care," Busby says. "Men without access to regular care should be offered high-caliber screening counseling, and they should get appropriate follow-up care."
Prostate cancer is the most common non-skin cancer found in American men. When it is detected early, prostate cancer often can be treated successfully; more than 2 million U.S. men who have been diagnosed with prostate cancer are alive today, Busby says.
The new guidelines provide detailed advice on the kind of information that should be discussed regarding the pros and cons of the screening tests, including the prostate-specific antigen (PSA) blood test and a digital rectal exam. The guideline's authors recommend an honest discussion of these issues and point out the need to distribute educational materials, including brochures or a video, to better explain uncertainties, risks and benefits of the tests.
The ACS recommends that men age 50 with no symptoms of prostate cancer who are in relatively good health should be active in making an informed decision with their physician about prostate screening.
Men at high risk - African-Americans and men with a father, brother or son diagnosed with prostate cancer before age 65 - should begin that informed-decision talk earlier, at age 45. Those at higher risk, such as men with multiple family members affected by the disease before age 65, should start talking about screening at age 40.
For men unable to make a decision about screening after these conversations, the ACS recommends a doctor decide whether or not to screen based on knowledge of a patient's health preferences and values. After a decision to screen is made, the new guidelines make the digital rectal exam portion of the testing optional, and they say it is acceptable to extend the period between screenings for men with low PSA levels.
Partridge says there are limits to both PSA and the digital-exam method, and even when these tests detect cancer, physicians often can't tell how dangerous the cancer is without further tests or medical procedures. Some prostate cancers grow slowly and never cause any problems; others may grow aggressively.
Physicians and cancer-prevention experts note the urgent need for better ways to detect and treat early-stage prostate cancer, particularly the need to distinguish between cancers that do not require treatment and those that are actively growing. The American Urological Association, for example, insists that shared decision-making should involve personal data that is more in-depth than age, such as ethnicity, family history, previous biopsy characteristics and other factors.
Until new screening tools are available, it is crucial for care providers and cancer-prevention program directors give men the opportunity to decide whether they wish to pursue early detection for this disease.