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May 21, 2013 Issue

Clinical Practice Points

Screening for Prostate Cancer: A Guidance Statement From the Clinical Guidelines Committee of the American College of Physicians

This guidance statement appraised the guidelines from major professional societies addressing screening for prostate cancer. The ACP recommends clinicians discuss the potential risks and benefits of screening in men aged 50 to 69 years, with consideration of a man’s general health and life expectancy. ACP recommends against screening men who do not express a clear preference for screening. ACP recommends against screening men younger than 50 years or older than 69 years who are at average risk, or in men with life expectancies less than 10 years.

Use this Guidance Statement to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Discuss the potential harms and benefits of screening for prostate cancer.
  • Review the "talking points" provided for discussions with patients (page 767). Why is screening controversial? Why do the chances of harm from PSA screening outweigh the chances of benefit in most men? Why is the PSA test not "just a blood test?"
  • Discuss what is required for a screening test to be useful. There are free, ready-to-use teaching materials, including slides, cases, and facilitator’s guides, available in the High Value Screening & Prevention module of the ACP High Value Care Curriculum for Educators, Residents, and Students.
  • Earn CME for yourself. As long as you’re reviewing this article to help you teach, you might as well help yourself by taking the brief CME quiz to earn credit!

Effect of Age, Tumor Risk, and Comorbidity on Competing Risks for Survival in a U.S. Population–Based Cohort of Men With Prostate Cancer

This observational study examined the effect of age, comorbidity, and tumor risk on other-cause and prostate cancer–specific mortality in men with early-stage disease. It found that other-cause mortality risk increased with the number of major comorbid conditions, especially in older men, and prostate cancer mortality varied according to disease risk (e.g., pathological features) but not the number of comorbid conditions.

Use this study to:

  • Discuss why one needs to consider disease-specific and other-cause mortality when assessing the harms and benefits of an intervention.
  • Discuss whether these data would be helpful when discussing treatment options with a man diagnosed with prostate cancer. Residents might use the lay summary of this article (see the Summary for Patients section) to help discuss such issues with patients.
  • Discuss the limitations of observational studies. How might the lack of information regarding certain clinical variables that influenced clinical decision making in the men included in this study have biased the results? What are the limitations of such observational studies compared with data from a randomized, controlled trial? Are there advantages? The authors address some of these issues in the Discussion section (page 713).

Update in Hematology and Oncology: Evidence Published in 2012

This concise update summarizes essential papers published in 2012 chosen for their clinical importance. Studies concisely presented include randomized trials of novel therapies for several cancers, including melanoma, metastatic prostate cancer, and metastatic breast cancer. Another randomized trial assessed target hematocrit levels for phlebotomy in patients with polycythemia vera. Other studies addressed which patients with colorectal cancer appear to benefit from aspirin therapy and a scoring system to exclude heparin-induced thrombocytopenia.

Use these summaries to:

  • Have a rapid-fire literature review of multiple important topics in hematology-oncology.
  • Create a series of resident reports or journal clubs, each dedicated to an internal medicine subspecialty. At each, review the seminal points from key articles reviewed in this series (we’ve assembled these concise summary articles for you here).

Humanism and Professionalism

When We Became Rich

Do your residents know where the money comes from to pay for their training? Do they know that changes to that system are being debated? Play the audio recordings of this issue’s On Being A Doctor essay. Dr. Sarosi recalls when Medicaid payments first arrived during his residency and the debate that ensued regarding who should get them.

Use this essay to:


mksap16

A 52-year-old man is evaluated during a periodic health examination. He has benign prostatic hyperplasia, and his father died of prostate cancer at the age of 74 years. His only current medication is tamsulosin. He has no urinary symptoms. Vital signs are normal, as is the remainder of the physical examination.

Which of the following is the most appropriate management?

A. Discuss the risks and benefits of prostate cancer screening
B. Obtain a prostate-specific antigen level
C. Perform a digital rectal examination
D. Perform a digital rectal examination and obtain a prostate-specific antigen level

Answer: A. Discuss the risks and benefits of prostate cancer screening

Key Point: The decision of whether or not to screen for prostate cancer in an individual man should begin with an informed discussion regarding the risks and benefits of screening and the limitations of the methods used to screen.

Educational Objective: Manage prostate cancer screening.

The most appropriate management is to have an informed discussion with the patient regarding the risks and benefits of prostate cancer screening. The European Randomized Study of Screening for Prostate Cancer included 162,243 men aged 55 to 69 years. During a median of 9 years, the rate of diagnosis of prostate cancer was higher in the prostate-specific antigen (PSA)-screened group (8.2%) compared with the control (non-screened) group (4.8%) and there was an absolute, albeit small, mortality benefit (1410 men would need to be screened and an additional 48 men would need to be treated for prostate cancer to prevent one death from prostate cancer). In contrast, the Prostate, Lung, Colorectal, and Prostate Cancer Screening Trial found no benefit for annual concurrent PSA and digital rectal examination (DRE) after 7 to 10 years of follow up. Given the conflicting evidence regarding the benefit of prostate cancer screening, the decision of whether or not to screen an individual patient should begin with the clinician having an informed discussion with the patient regarding the risks and benefits of screening and the limitations of the methods used to screen. Based on the conflicting results of these trials, it is not surprising that there is little consensus in terms of screening recommendations. The American Cancer Society supports the need for men to be involved in the decision of whether or not to be screened. In 2012, the U.S. Preventive Services Task Force (USPSTF) published a formal recommendation statement based on a review of existing evidence advising against PSA testing for prostate cancer screening in all men.

Performing a DRE alone is not recommended for screening owing to the poor test characteristics (positive likelihood ratio, 0.53-1.33; negative likelihood ratio, 0.65-14.9).

Although obtaining a PSA level alone and performing a DRE in combination with obtaining a PSA level are frequently employed in screening for prostate cancer, neither approach should be performed without first having an informed discussion with the patient.

Bibliography
Chou R, Croswell JM, Dana T, et al. Screening for prostate cancer: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2011;155(11):762-771. Epub 2011 Oct 7. PMID: 21984740

This question was derived from MKSAP® 16, the latest edition of the Medical Knowledge Self-Assessment Program.


From the Editors of Annals of Internal Medicine and Education Guest Editor, Erin Ney, MD, FACP Assistant Residency Program Director, Department of Internal Medicine, Thomas Jefferson University.

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