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USPSTF vs ACP vs AUA: Alphabet Soup re Prostate Cancer Screening w/PSA

Posted May 10 2013 3:00am
Want to see a bunch of physicians get in a fight?  Ask them for their opinion regarding screening for prostate cancer, especially their views regarding use of prostate specific antigen.   Exactly a year ago, the US Preventive Services Task Force came out against PSA-based screening for prostate cancer in all men, regardless of age .  I led a discussion on this topic during the American Academy of Family Physicians' Geriatric Medicine conference last month in Santa Ana Pueblo, NM  and boy did it get heated.

I think the best way to describe the interaction was an agreement to disagree between those who had an experience with prostate cancer, either personal or family, vs those who had not.  The former tended to come out in favor of doing some sort of screening, even using the imperfect PSA, while the latter felt just as strongly about the USPSTF guidelines, especially given all the possible complications once screening is started for a disease that most men will die with, not from.

Of note, USPSTF comes out rather strongly, almost heavy handily against screening, not even making any suggestion to discuss risks, benefits & alternatives with one's patients.   Just prior to the conference (but after the presentation deadline had passed), the American College of Physicians published early online in Annals of Internal Medicine their clinical guidelines suggesting that physicians inform 50-69yo men of the risks, benefits & alternatives to screening for prostate cancer.  The ACP did not recommend screening average-risk men younger than 50yo or older than 69yo.  Furthermore, the ACP also did not recommend screening those with life expectancy less than 10-15yrs.

Most recently, the American Urological Association tossed their hat into the guideline arena but in a very nuanced fashion .  The AUA recommends against screening w/PSA in men younger than 40yo but "does not recommend routine screening" in those 40-54yo.  And for men 55-69yo, the AUA "strongly recommends shared decision making".  In those who still desired screening, the AUA also came out in favor of testing every 2 years rather than annually.  
So what are we supposed to do?  Make no mention or offer at any age?  Set aside even more precious time to discuss the above in detail?  And if the latter, at which age group would you start?  There's no single right answer for every provider so read the guidelines for yourself and come to your own decision.

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