Recent recommendations from the U.S. Preventive Services Task Force(USPSTF) advising elimination of routine prostate-specific antigen(PSA) screening for prostate cancer in healthy men are likely to encounter serious pushback fromprimary care physicians, according to results of a survey by JohnsHopkins investigators. In a survey of 125 primary care doctors, the researchers found thatwhile doctors agreed with older recommendations to curtail routinescreening in men over age 75 and among those not expected to live10 or more years, a large number said they faced significantbarriers to stopping PSA testing in men who had been receiving itregularly. The most frequently cited reason by 74.4 percent ofphysicians was, "My patients expect me to continue getting yearlyPSA tests," followed by 66 percent of them who said, "It takes moretime to explain why I'm not screening than to just continuescreening." More than half of those surveyed in the new studybelieved that, "By not ordering a PSA, it puts me at risk formalpractice." The survey was conducted in November 2011, right after draftrecommendations were made to end routine screening of all men, butbefore last week, when the draft recommendations were officiallyapproved. |
"It can be very difficult for doctors to break down the belief thatall cancer screening tests are invariably good for all people all the time,"says Craig E. Pollack, M.D., M.H.S., an assistant professor in theDivision of General Internal Medicine at the Johns HopkinsUniversity School of Medicine, and leader of the study publishedonline in the journal Cancer. "Everyone agrees that PSA screeningisn't as good as we want it to be. If we had a test that was a slamdunk, it would be different. But now we know that for many men, thebenefits may be small and the harms significant." Each year, more than 33,000 American men die of prostate cancer,and 20 million get the PSA test to detect the disease early.
According to the USPSTF, evidence suggests the potential harmscaused by PSA screening of healthy men as a means of identifyingprostate cancer outweigh its potential to save lives and thatroutine annual screening should be eliminated in the healthy.Elevated PSA readings are not necessarily evidence of prostatecancer, and can lead to unnecessary prostate biopsy. In addition,even when biopsies reveal signs of prostate cancer cells, evidenceshows that a large proportion will never cause harm, even if leftuntreated. The disease in older men often progresses slowly so thatthose who have it frequently die of other causes. Treatments for prostate cancer can include the removal of theprostate, radiation or other therapies, each of which has thepotential to cause serious problems like erectile dysfunction , complete impotence, urinary incontinence or bowel damage. And men who choose to "watch and wait" afterelevated PSA readings must live with the anxiety of knowing they have an untreated cancer that could start toprogress.
In the new study, Pollack and his colleagues found that while mostphysicians said they took age and life expectancy into account whendeciding to order PSA screening, many also said they had a hardtime estimating life expectancy in their patients and could use abetter tool. H. Ballentine Carter, M.D., a professor of urology atJohns Hopkins and the senior investigator on the study, is planningto investigate the potential of individualized prostate cancerscreening recommendations. Specifically, he and colleagues plan tocreate a decision-making tool that incorporates age, lifeexpectancy, family history and prior PSA results in order to helpdoctors and their patients make better choices for prostate cancerscreening. In another report derived from results of Pollack's and Carter'ssurvey, published in April in the Archives of Internal Medicine,the researchers say nearly half of the providers agreed with thenew USPSTF recommendations to eliminate routine screening forhealthy men.
Still, less than two percent said they would no longerorder routine PSA screening in response to the draftrecommendations; 21.9 percent said they would be much less likelyto do so; 38.6 percent said they would be somewhat less likely todo so; and 37.7 percent said they would not change their screeningpractices. "Men often expect PSA screening to be part of their annualphysical," Pollack says. "To change their minds, we need to addresstheir perceptions about screening, allow time for screeningdiscussions and reduce concerns regarding malpractice litigation." Additional References Citations.
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