A More Personalized Approach to PSA Screening in 2017

FG_AUTHORS: MedPage Today

In April, the U.S. Preventive Services Task Force (USPSTF) released an updated recommendation supporting individualized decision-making for PSA-based prostate cancer screening among men ages 55 to 69, and MedPage Today surveyed prominent physicians for their thoughts about it. Click here to see what they told us then. In this follow-up, we examine how attitudes among physicians may have evolved in the months since.

While the previous statement recommended against routine PSA screening for men of any age, the draft released in April stated that men should have the opportunity to weigh the potential benefits and harms of screening and make a decision based on their own values and preferences. The recommendation applies to men who have an increased risk of prostate cancer due to race or family history, as well as to average-risk men, but the recommendation against screening in men ages ≥70 remained the same.

The 2017 update better aligns with guidances from the American Urological Association (AUA) and the American Cancer Society (ACS) and was well received by physicians throughout the country.

When asked for his thoughts on the updated recommendation, David F. Penson, MD, MPH, of Vanderbilt University Medical Center in Nashville, responded: "This is good because the earlier recommendation against screening from the USPSTF made it difficult for primary care providers to figure out whether or not to screen men for prostate cancer, which resulted in a drop in screening and new diagnoses of prostate cancer, which may have some very negative effects over time."

Penson wasn't the only physician to express concern with the previous recommendation.

"The prior guidelines were resulting in an increased incidence of more aggressive prostate cancers as a result of a lack of screening," Alexander W. Pastuszak, MD, of Baylor College of Medicine in Houston, told MedPage Today: "The modified guidelines bridge that gap by effectively endorsing some level of PSA-based screening -- a mortality benefit which is supported by numerous clinical trials."

William K. Oh, MD, of Icahn School of Medicine at Mount Sinai in New York City, shared a similar but more cautious perspective: "When the previous recommendation was announced that patients should not be screened at all, I do think it decreased screening rates," he explained via email. "I think this change will slowly increase screening again, but I don't think it will happen quickly. Unfortunately, I think these rapid back-and-forth changes have the effect of causing clinicians to become confused and potentially not respond to guidelines."

Has This Changed Screening Rates?

A recent study showed that one-third of men did not discuss the pros and cons of PSA tests with clinicians prior to testing -- suggesting that the new guideline might be a necessary step toward providing more discussion-driven, patient-centered care.

Penson said that while he was already practicing individual decision-making, the update "has allowed us to explore new ways to implement shared decision-making, including using established nomograms when counseling patients."

When asked to comment on any observed trends following the new recommendations, he replied: "It seems like we are seeing more patients getting their PSA checked by their primary care physicians since the USPSTF has changed their grade recommendation to a C. I think when the recommendation was a grade D, primary care physicians didn't bring it up with patients and just didn't screen at all. Now, they are asking their patients if they are interested and having at least a cursory discussion about the pros and cons of screening."

Pastuszak commented that he now considers the modified age range for screening, and also engages in a more personalized discussion with screened patients around shared decision-making. "I've also started using the prostate health index (PHI), a new PSA-based prostate cancer test that provides additional discrete data on prostate cancer likelihood," he added.

While the consensus is that discussing the pros and cons of PSA testing is good medicine, there are also concerns that a thorough discussion may not fit within the time allocated for a typical patient visit. "I make sure to emphasize that PSA screening does not necessarily mean that all prostate cancers need treatment," said Oh. "Active surveillance is a reasonable and safe option for men with low-grade cancers who are unlikely to benefit from surgery or radiation. However, PSA screening can pick up more lethal cancers that may be cured if caught early. Unfortunately it is no easier to have this conversation in a 15-minute visit now than it was 5 years ago."

What's to Come in 2018?

Although it has been less than 10 months since the update, physicians said they expect to see how physician-patient dialogue will influence health outcomes within the next year.

"Based on the revised USPSTF recommendations, I anticipate the number of men receiving PSA screening will increase," commented Ronald C. Chen, MD, MPH, of the University of North Carolina at Chapel Hill. "I believe fewer men will be diagnosed with aggressive or advanced cancers, which have a poorer prognosis."

Howard Sandler, MD, of Cedars-Sinai Medical Center in Los Angeles, also remains optimistic, saying that he believes that future screening data will offer the medical community more secure evidence for or against PSA screening.

2017-12-29T13:00:00-0500

Read more http://www.medpagetoday.com/urology/prostatecancer/70181

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