So what is new with all this. It’s the part about informed consent and having a PSA drawn. Do you know what that is about ? “Men should discuss the uncertainty, risks, and benefits of prostate screening . That would mean that the discussion of prostate cancer in all of those areas are discussed at an office visit before PSA is even drawn. I must say I have a pretty tough time discussing the nuances of prostate cancer after the diagnosis is made, much less before the PSA is drawn. Now that is prostate cancer awareness! Is it a bad idea, no. I do see a problem in implementing it however. It is about telling a patient the potential of a long cascade of events that may be perpertrated upon him by the drawing of the PSA.
Is this how it would go? “Hello Mr. Smith. My name is Dr. McHugh and I want to obtain your permission to draw a blood test to see if you are at risk for prostate cancer. First of all you will have to pay for the test. If it is high it may be a lab error or it may mean you have prostate cancer. If it is high, we may need to repeat it to confirm that it is high. In this scenario we would then discuss a prostate biopsy. If you agree to the biopsy, there are risks related to the biopsy that we would discuss, primarily bleeding and infection, and the possibility that the biopsy is negative. If it is negative you still could have prostate cancer because we only take about 12 specimens and if your cancer is low volume we may not have hit it. If your prostate biopsy is positive, it may be low volume, low Gleason’s grade and we won’t be able to tell you if it is a cancer that will one day kill your or one you could live with. Right now we don’t know the difference. You could be treated and did not need it, or not be treated and ultimately die from it. If you are treated there is a possibility that you will be incontinent or impotent. If you elect to do nothing ,and your cancer spreads, by the time we determine that it will be too late. In that case we could use hormone therapy, which often times temporarily fights the cancer and will give you symptoms like your wife had when she went through menopause. If your biopsy is obviously clinically significant, high volume and high Gleason’s on your biopsy cores, you will more likely need treatment. Depending on your age, health and inclinations you would choose surgery or radiation or other modalities such as cryosurgery or HIFU. Whichever treatment you choose there is still a chance that you will have all the complications and that the cancer is not cured and that you will need hormone therapy anyway. If you do elect to have surgery you will need to decide between robotic or open, if radiation between external beam , seed therapy or a combination of both. ” So, Mr. Smith. Mr. Smith? What do you think? Do you want me to draw the PSA blood test?” “What for?” Mr. Smith asks. “To see if you may have prostate cancer.” “But I don’t have any symptoms.” “Well you don’t always have symptoms with prostate cancer.” “Well,” says Mr. Smith , “I think I’ll wait on that. Do you have any Viagra samples?”
American Cancer Society Updates Prostate Cancer Screening Guidelines Update Reaffirms the Importance of Shared Decision-Making
Atlanta 2010/03/03 -Newly updated prostate cancer screening guidelines from the American Cancer Society reaffirm the recommendation that men should discuss the uncertainties, risks and potential benefits of screening for prostate cancer before deciding whether to be tested. The update is the first since 2001 and was done as part of the Society’s regular guidelines update process. It included a series of systematic reviews focusing on the latest evidence related to the early detection of prostate cancer, screening test performance, harms of therapy for localized prostate cancer, and shared and informed decision making in prostate cancer screening.The guideline is published online in advance of print publication in CA: A Cancer Journal for Clinicians.The updated guidelines include these recommendations:
- Asymptomatic men who have at least a ten-year life expectancy should have an opportunity to make an informed decision with their health care provider about screening for prostate cancer after receiving information about the uncertainties, risks, and potential benefits associated with screening.
- Men at average risk should receive this information beginning at age 50. Men at higher risk, including African American men and men with a first degree relative (father or brother) diagnosed with prostate cancer before age 65, should receive this information beginning at age 45. Men at appreciably higher risk (multiple family members diagnosed with prostate cancer before age 65) should receive this information beginning at age 40.
- Men should either receive this information directly from their health care providers or be referred to reliable and culturally appropriate sources.
- Patient decision aids are helpful in preparing men to make a decision whether to be tested.
- Prostate cancer screening should not occur without an informed decision making process.
- Asymptomatic men who have less than a ten-year life expectancy based on age and health status should not be offered prostate cancer screening.
- For men who are unable to decide, the screening decision can be left to the discretion of the health care provider, who should factor into the decision his or her knowledge of the patient’s general health preferences and values.
“Two decades into the PSA era of prostate cancer screening, the overall value of early detection in reducing the morbidity and mortality from prostate cancer remains unclear,” said Andrew M. Wolf, M.D., Associate Professor of Medicine at the University of Virginia Health System and Chair of the Advisory Committee. “While early detection may reduce the likelihood of dying from prostate cancer, that benefit must be weighed against the serious risks associated with subsequent treatment, particularly the risk of treating men for cancers that would not have caused ill effects had they been left undetected.” The authors say in light of ongoing uncertainties, including the uncertain balance between benefits and risks, involving men in the screening decision is crucial.“With these newly updated recommendations, the American Cancer Society places even stronger emphasis on shared decision making between clinicians and patients,” said Otis W. Brawley, M.D., chief medical officer of the American Cancer Society. “The decision whether to screen should be made with the help of a trusted source of regular care. Men without access to regular care should not be tested unless high-quality informed decision-making as well as appropriate counseling and follow-up care for those who test positive can be assured. Without those, community-based screening should not be initiated.”“Previous guidelines from the American Cancer Society and other organizations have discussed the importance of informed decision making for men who are considering prostate cancer screening, however this update is the first to provide details regarding what information about screening is needed for informed decision-making to occur,” said Alan G. Thorson, M.D., F.A.C.S., volunteer president of the Society. “For that reason, the updated ACS guidelines delineate the core elements of information necessary for men to engage meaningfully in this decision, and encourage inclusion of this information in patient discussions and decision aids.”The guidelines also includes updated clinical recommendations regarding screening tests, intervals, and follow up of abnormal results for those men who choose to be screened after considering the possible benefits and risks. The guidelines acknowledge the limited contribution of digital rectal exam (DRE) to prostate cancer early detection and state that screening can be performed using PSA with or without the DRE. The guidelines recommend annual screening for men whose PSA level is 2.5 ng/ml or higher, but state that screening intervals can be safely extended to every two years for men whose PSA is less than 2.5 ng/ml. The guidelines affirm that a PSA level of 4.0 ng/ml or higher remains a reasonable threshold to recommend referral for further evaluation or biopsy for men at average risk of developing prostate cancer; for PSA levels between 2.5 and 4.0 ng/ml, health care providers should consider an individualized risk assessment that incorporates other risk factors for prostate cancer in the referral decision.The update included a complete review of the evidence. The American Cancer Society’s Prostate Cancer Advisory Committee, composed of independent researchers, clinicians and lay people, examined systematic reviews done by scientific experts at Emory University, Rollins School of Public Health, met to hear presentations by experts both on the Committee and by invited outside experts, and deliberated the evidence before making its final recommendations. The guideline underwent peer review before going before the American Cancer Society volunteer Board of Directors for approval.The authors conclude by noting 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 aggressive, to help “tip the balance clearly in favor of screening. Until that time, however, it will remain incumbent on health care providers and the health care system as a whole to provide men with the opportunity to decide whether they wish to pursue early detection of prostate cancer.”About the American Cancer SocietyThe American Cancer Society combines an unyielding passion with nearly a century of experience to save lives and end suffering from cancer. As a global grassroots force of more than three million volunteers, we fight for every birthday threatened by every cancer in every community. We save lives by helping people stay well by preventing cancer or detecting it early; helping people get well by being there for them during and after a cancer diagnosis; by finding cures through investment in groundbreaking discovery; and by fighting back by rallying lawmakers to pass laws to defeat cancer and by rallying communities worldwide to join the fight. As the nation’s largest non-governmental investor in cancer research, contributing about $3.4 billion, we turn what we know about cancer into what we do. As a result, more than 11 million people in America who have had cancer and countless more who have avoided it will be celebrating birthdays this year. To learn more about us or to get help, call us any time, day or night, at 1-800-227-2345 or visit cancer.org.
<!—->Newly updated prostate cncer screening guidelines from the American Cancer Society reaffirm the recommendation that men should discuss the uncertainties, risks and potential benefits of screening for prostate cancer before deciding whether to be tested.