The Americans may have moved closer to the idea of national screening for prostate cancer, with a leading body recommending PSA tests for men aged 40.
Although the American Urological Association – which issued a new statement on testing this week – doesn’t actually say a national screening programme should now be implemented by the US government, its new stance goes further than previous guidelines.
With the notable exception of NZ Doctor, there has been no NZ media coverage of the US situation as yet, and cancer and government organisations in New Zealand may or may not be monitoring the debate.
If they are, the question arises: should this country be reviewing its “no national prostate screening” policy yet again?
The key points in the AUA’s statement yesterday are:
- PSA testing should be offered to well-informed men aged 40 years or older who have a life expectancy of at least 10 years;
- when offered and interpreted appropriately the PSA test may provide essential information for the diagnosis, pre-treatment staging or risk assessment and post-treatment monitoring of prostate cancer;
- a baseline PSA level above the median for age 40 is a strong predictor of prostate cancer. Such testing may not only allow for earlier detection of more curable cancers, but may also allow for more efficient, less frequent testing;
- other factors such as family history, age, overall health and ethnicity should be combined with the results of PSA testing and physical examination in order to better determine the risk of prostate cancer;
- prostate cancer testing is an individual decision that patients of any age should make in conjunction with their physicians and urologists. There is no single standard that applies to all men, nor should there be at this time;
- the AUA does not recommend a single PSA threshold at which a biopsy should be obtained. Rather, the decision to biopsy should take into account additional factors, including free and total PSA, PSA velocity and density, patient age, family history, race/ethnicity, previous biopsy history and co-morbidities;
- the bottom line about prostate cancer testing is that we cannot counsel patients about next steps for cancer that we do not know exist.
So what’s changed?
Point 1: The first point about testing 40-year-olds is new. The aim appears to be to see what men’s natural PSA levels are (establish a baseline level) before they enter the prostate danger zone after about 50. Changes to PSA levels are a more significant indicator of trouble than actual level, so subsequent monitoring would note anything moving. At this stage, we don’t know what the AUA means by a “well-informed” man.
Point 2: This seems to be countering the standard arguments about national screening creating a risk of “over-diagnosis” and “over-treatment” – ie, men being persuaded into treatment when the cancer might be harmless. The AUA may be saying that used properly, the PSA is a more than useful test (not a view held by all in the medical profession).
Point 3: The radical idea of getting in so early (40) not only establishes a man’s baseline antigen levels, but gives a really early chance to apply treatment if something is found.
Point 4: This reinforces the point made in 2) – that done properly, this whole process works.
Point 5: Here, however, the AUA is having a bet each way, it seems. If something is found, the decision will still lie with the patient, suggesting we are not much further ahead in diagnosing what’s dangerous and what can be left for surveillance.
Point 6: This seems to broaden the criteria for considering a biopsy if the PSA shows something. A reinforcing clarification, perhaps.
Point 7: A number of interpretations could be drawn from this comment. It’s saying if we don’t test, how can we advise? Is this is an indication that the AUA is warming to the idea of national screening.
Really, it’s not very clear what exactly the association is trying to say, and US media coverage has been muted and varying in its interpretations
All of these points may be clarified further when the AUA issues its formal guidelines soon.
For the full text of the AUA statement, click HERE>
Ministry of Health policy on screening (2008) – HERE>
NZ Medical Journal paper on screening (2005) – HERE>
NZ Cancer Society policy on screening (1999) – HERE>
To vote in our poll on prostate screening, click HERE>
Prostablog 
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