In late 2011, the U.S. Preventive Services Task Force (USPSTF), a
government-backed panel of independent physicians, recommended
against routine prostate cancer tests for all men. They cited
concerns that widespread screening often caught harmless tumors that
didn’t need treatment and led to unnecessary procedures with side
effects like impotence and incontinence.
The next year, testing rates for prostate cancer among men aged 50
to 74 years old dropped to about 16 percent among primary care
physicians, from roughly 37 percent in 2010 before new guidelines
But among urologists, use of the test for a substance in the blood
called prostate-specific antigen (PSA) decreased only about 4
percentage points to about 35 percent over the same period,
researchers report in JAMA Internal Medicine.
“There is much evidence that men with limited life expectancy do not
benefit from PSA testing, and I think experts can agree on that,”
said senior study author Dr. Quoc-Dien Trinh, a urologist at Brigham
and Women’s Hospital in Boston.
“The rest is a matter of opinions and expert panels,” Trinh added by
email. “I do feel strongly that some men are more at risk of
prostate cancer and I’m concerned about what will happen to these
men given the current USPSTF recommendations and trends in PSA
Both the American Cancer Society and the American Urological
Association recommend that men discuss the benefits and harms of
screening with doctors to make a joint decision. Among other things,
patients should consider that black men and those with a family
history of prostate cancer are at greater risk.
To see whether the type of physician patients see influences
screening, Trinh and colleagues analyzed nationally representative
survey data on 64 men who went to urologists for preventive care
visits and 1,100 who saw primary care physicians. None had a history
of tumors or other prostate problems.
The sample represents approximately 800,000 visits to urologists and
26 million visits to primary care doctors, nationwide, in 2010 and
One limitation of the study is that researchers relied on orders for
PSA screening, which might not accurately reflect how many tests
were performed, the authors note. They were also unable to see test
results to assess how different doctors may have defined elevated
Even so, the differences in screening rates and changes in PSA
testing over time likely reflect opposing perceptions among
physicians about the benefit of screening as well as the conflicting
guidelines, researchers conclude in JAMA Internal Medicine.
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Recent decreases in screening have been associated with some decline
in the detection of early-stage prostate cancer, journal editor Dr.
Rita Redberg of the University of California San Francisco noted in
an accompanying editorial.
It will take much longer, however, to understand how this impacts
the number of men diagnosed with advanced tumors and prostate cancer
deaths, noted Redberg.
The limited drop in PSA testing by urologists probably reflects a
belief among specialists that they’re doing what’s best for
patients, as well as a payment system that rewards more screening,
not less, Redberg added by email.
Urologists may also see more patients who want aggressive treatment,
while primary care physicians may see more older, sicker men who
aren’t good candidates for screening, said Dr. Alexander Kutikov, a
urologic oncology specialist at Fox Chase Cancer Center in
Philadelphia who wasn’t involved in the study.
“Regardless of what specialist a patient approaches to discuss PSA
screening, patients must understand that decisions regarding
screening are exceedingly personal,” Kutikov said by email.
Though most men will die with and not of prostate cancer, some
doctors and patients may still hesitate to forgo screening because
the disease is curable only when it’s caught before it spreads,
“What is the right decision for one person may not be right for
another,” Kutikov said.
SOURCE: http://bit.ly/IZGqPC JAMA Internal Medicine, online February
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