Prostate Screening Not For Everyone Physicians Group Says Early Detection, Treatment Holds Risk

The American College of Physicians, in a break with what has become a widespread practice, has concluded that there is no evidence that patients benefit from routine screening for prostate cancer and recommends against regular testing for all men.

“Screening for prostate cancer is not for everyone,” said Harold C. Sox Jr., the group’s president-elect designate.

Because of uncertainties in the reliability of the tests, and the substantial risks of aggressive early treatment, the organization decided screening should be undertaken as an “individualized decision” of each patient after counseling by physicians.

The new guidelines, published in today’s issue of the Annals of Internal Medicine, are at odds with recommendations of the American Cancer Society and other medical groups.

The American Cancer Society, the American College of Radiology and the American Urological Association recommend that men begin undergoing annual digital exams at age 40. The cancer society recommends also getting annual prostate-specific antigen (PSA) tests beginning at age 50.

But the ACP, an organization of 100,000 internal medicine specialists, in its first set of recommendations on the issue, now advises that “rather than screening all men for prostate cancer as a matter of routine, physicians should describe the potential benefits and known harms of screening, diagnosis and treatment, listen to the patient’s concerns, and then individualize the decision to screen.”

The differences between the two sets of guidelines - analogous to the nationwide dispute over the best age for women to begin having regular mammograms - reflect the tradeoffs and uncertainties inherent in diagnosing and treating the highly variable disease, which strikes about one in five American men at some time in their lives and will kill an estimated 41,800 this year.

Increased PSA screening, which became broadly available in the late 1980s, reportedly has led to a six-fold increase in surgical removals of the prostate, a gland that lies below the bladder and encircles the urethra.

In many cases, both patients and physicians have wondered whether the risks of early aggressive treatment - including impotence, urinary incontinence, bowel problems and even death - may outweigh the threat of prostate cancer, which often develops so slowly that sufferers die of some other cause before the cancer becomes a severe problem.

Compounding the quandary, said ACS senior vice president Herbert S. Waxman, is the frustrating absence of conclusive evidence that early detection improves a patient’s outcome. “It’s not like screening for high blood pressure, where the benefits are absolutely compelling,” he said. An exhaustive study of published research, he said, led to “the conclusion that there was no evidence that a screened population had an advantage in survival or degree of illness” compared with unscreened patients.