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“Many of the points brought up by the Task Force regarding the PSA test — such as that it was used for men who would not benefit from screening or that lower and lower levels of PSA led to biopsies — were valid,” said Dr. James Eastham, a prostate cancer surgeon who is chief of urology at Memorial Sloan-Kettering Cancer Center in New York. “But their conclusion that no one should get screened, we don’t agree with.”
Most vehement among the critics, perhaps, was the American Urological Association, which issued a swift and strongly worded response expressing “outrage” at the new guidelines and stating that: “It is inappropriate and irresponsible to issue a blanket statement against PSA testing, particularly for at-risk populations.”
Those known to be at higher risk from prostate cancer include African-American men, men with a history of prostate cancer in their families and those who carry BRCA mutations. Men in these groups are more likely to develop the disease and, more importantly, either die from it or experience symptoms.
Researchers have found that men with BRCA mutations are more likely to develop prostate cancer at a younger age. Men with a mutation on the BRCA2 gene, in particular, are more likely to develop a more aggressive form of the disease. The rate of BRCA mutations among Ashkenazi Jews is one in 40, compared with a rate of one in 500 in the general population.
“The Task Force did not specifically look at men with BRCA mutations,” said LeFevre, who added, “Unfortunately, the trials did not have enough high-risk men to allow us an informed decision about those groups.”
But many experts are concerned that such caveats are buried in the guidelines, and patients and primary care physicians, for whom the guidelines are intended, will get only the general message to simply stop PSA screening on all men.
“There are groups out there who are saying we are over-screening and over-treating, and that may be partly true, but we need to know who is at highest risk of developing and dying from prostate cancer.If you make a blanket statement, then you may be missing people who are at greater risk,” said Sue Friedman, president of FORCE, a national advocacy group for individuals with hereditary breast and ovarian cancers that provides support and information for individuals with BRCA mutations.
“We need to move away from a one-size-fits-all system of screening and prevention.”
Preliminary findings from IMPACT, an international study examining the benefit of prostate cancer screening tests for men who are carriers of a BRCA mutation, have so far shown the PSA test to be promising in detecting cancer early in this group. “Until the day when we can do more personal evaluation, PSA is still valuable for this high-risk population,” said Jacquelyn Powers, a cancer genetic counselor at the University of Pennsylvania’s Abramson Cancer Center and part of the IMPACT study.
Furthermore, among the approximately 1,200 men it has studied since 2005, IMPACT found identifiable prostate cancer in about half the men who had elevated PSA levels, tested positive for a BRCA2 mutation and elected to have a biopsy. Although the total numbers were quite small when compared with the control group, there was also a greater incidence of more aggressive prostate cancers within this group.
“We want to be diagnosing cancers in this group early, because we want to be treating them,” said Powers, who added that the IMPACT survey should be completed sometime between 2016 and 2018.
“We have to use PSA intelligently,” said Dr. James Mohler, chair of urology at Roswell Park Cancer Institute in Buffalo and chair of the National Comprehensive Cancer Network (NCCN) Guidelines Panel for Prostate Cancer. “We need to perform these tests in men who are at increased risk of developing a prostate cancer, who, if they develop that prostate cancer, are likely to die of it and for whom we can prevent that death by treating them.”
The NCCN, a consortium of 21 of the world’s leading cancer centers, has published its own guidelines for PSA testing, as has the American Urological Association and Memorial Sloan-Kettering. The NCCN recommends that all men get a baseline PSA test at age 40. The results, as well as a man’s general health, would determine the frequency of testing. For men at higher risk, such as from a BRCA mutation, Mohler said he would start testing early, at age 30.
Echoing most health care professionals, Mohler said that, ultimately, decisions about PSA testing are personal ones, to be made by a man in consultation with his physician. “I tell men they should religiously follow their guideline of choice,” said Mohler, “A guideline is a guideline and not a rule. Every person thinks of their mortality and morbidity differently.”
For Adland, already being watched for his BRCA risk, the new guidelines are not likely to change his care. “I’m the guy who leaves things up to his doctor; as long as he understands it, I’m fine.”
Talia Bloch writes on culture, religion, and science. Contact her at firstname.lastname@example.org