Physicians screening more patients for prostate cancer

December 05, 2001

Doctors report increased use of prostate specific antigen tests to screen for early stage prostate cancer, according to a new study. Although increased screening is generally seen as a good thing, in this case, it may not be driven by medical decision-making.

In 1998, primary care physicians reported ordering PSA tests in 81 percent of routine health maintenance exams for men over 50 compared with 73 percent in 1993.

"Our results contrast with other studies that have shown that a primary or important reason for PSA testing was belief that aggressive treatment would reduce mortality or that screening would reduce mortality," say lead authors John D. Voss, M.D., and Joel M. Schectman, M.D., M.P.H., of the department of internal medicine at the University of Virginia Health System in Charlottesville.

Fewer than half the physicians surveyed in 1998 thought that early detection and treatment of prostate cancer would reduce the death rate, according to the study. They were more likely to offer routine screening because they thought that it was a standard of care and because they thought that they would be at risk of malpractice suit if a patient who was not screened later developed prostate cancer.

The results are published in the December issue of the Journal of General Internal Medicine.

Prostate cancer is the second most common cause of death due to cancer in American men. Approximately 200,000 new cases are diagnosed every year.

In 1993, the researchers received responses to their survey from 176 general internists and family practitioners who contracted with a health maintenance organization in metropolitan Washington, D.C. The questionnaire asked the physicians how frequently and why they screened men without symptoms of prostate cancer during routine exams. The researchers then received responses to a second survey from 108 of these 176 physicians in 1998.

Between 1993 and 1998, 43 percent of the physicians reported that they more frequently screened for prostate cancer with a PSA test in patients without symptoms, and 13 percent said they were less likely to order PSA tests.

Two-thirds of the physicians believed that PSA screening should be offered to all men starting at age 50, and 75 percent thought these tests should be given to all men over 40 years old who were at high risk of getting prostate cancer.

Since the PSA test was introduced, physicians have been able to detect prostate cancer before men start to experience symptoms, leading to earlier treatment. However, it is not clear if earlier treatment leads to fewer deaths.

Because of the lack of data proving that PSA screening reduces mortality from prostate cancer, several prominent organizations, including the American College of Physicians, the U.S. Preventive Services Task Force, the American College of Preventive Medicine and the American Academy of Family Practice, do not recommend routine PSA screening or recommend it only as an option after careful discussion of risks and benefits on an individual patient basis.

The American Urologic Association, however, does advocate use of routine PSA screening and the American Cancer Society recommends that physicians offer PSA screening to all men who are at least 50 years old and who have an average risk of developing prostate cancer and have a life expectancy of at least 10 years.

"Prostate cancer is an important health problem that can be diagnosed in a pre-symptomatic stage. However, screening programs are only effective when treatment at the pre-symptomatic stage improves patient mortality or other important outcomes, a point still unsettled in the case of prostate cancer," say Voss and Schectman.

Further research is essential to improve screening and treatment for prostate cancer. "Clinicians need objective guidelines based on clinical data instead of the current contradictory guidelines," they say.
The Journal of General Internal Medicine, a monthly peer-reviewed journal of the Society of General Internal Medicine, publishes original articles on research and education in primary care. For information about the journal, contact Renee F. Wilson at (410) 955-9868.

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