Prostate cancer: To screen or not to screen?

Prostate cancer is one of the leading causes of cancer deaths in U.S. men, and 2011 guidelines from the U.S. Preventive Services Task Force (USPSTF) recommending against routine screening with prostate specific antigen (PSA) are often met with resistance among many primary care providers.

Only 50% of 124 physicians and nurse practitioners employed at community health-care sites affiliated with Johns Hopkins University agreed with the USPSTF recommendations, results of a recent survey published in Archives of Internal Medicine indicate. Another 36% disagreed and the remainder did not have an opinion on the topic.

Traditionally, clinicians screened for prostate cancer by performing a digital rectal exam (DRE) to determine the presence of nodules, pain or prostate enlargement. But many have taken to evaluating PSA levels in conjunction with DRE, due to the subjectivity and potential inaccuracies of DRE alone.

Proponents of PSA screening cite data that show early identification of localized prostate cancer is associated with a 100% five-year survival rate.

But the USPSTF guidelines argue that widespread PSA screening was adopted without a large evidence base from randomized controlled clinical trials. They contend PSA screening can lead to over-diagnosis and aggressive treatment in men with a less than 10-year life expectancy, who would not otherwise develop clinically significant disease.

But many patients are aware that early detection decreases mortality, and often request PSA screening. In these instances, the USPSTF recommends clinicians educate patients on the risks and benefits of screening to enable them to make an informed decision on the topic.

So will there be a decrease in the use of PSA levels for prostate cancer screening?

It will be difficult to convince both patients and providers that routine screening is not necessary. Providers are often fearful they will miss an early diagnosis, and patients are attracted to the reassurance that normal lab values provide. Although necessary to reduce unnecessary treatment and spending, the process will be challenging.

Do you have any tips for counseling patients about the risks and benefits of PSA screening? Please share them below.

Leigh Montejo, MSN, FNP-BC, provides health care to underserved populations at the Metropolitan Community Health Service's Agape Clinic in Washington, North Carolina.

References:

Pollack CE et al. Arch Intern Med. 2012;172(8):668-670.

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