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Prostate cancer guidelines irk some docs

Many doctors don't expect new guidelines to affect how often they screen men for prostate cancer, results of a new survey suggest.
/ Source: Reuters

Many doctors don't expect new guidelines to affect how often they screen men for prostate cancer, results of a new survey suggest.

Last fall, the U.S. Preventive Services Task Force (USPSTF) issued a draft of new prostate cancer screening guidelines, which recommend against routine prostate specific antigen (PSA) testing in average-risk men.

The federally-funded panel concluded there was "moderate certainty" that the harms of routine screening -- such as exposing men to more invasive tests and treatment that many might not need -- outweigh the benefits of catching some cancers early.

"It was quite a controversial decision, as some of the trials have led to differing positions," said Dr. Craig Pollack from the Johns Hopkins University School of Medicine in Baltimore, who worked on the new study.

That may be why only about half of all doctors and nurse practitioners his team surveyed agreed with the draft guidelines, Pollack said. And even among those in agreement, not all said they would significantly cut back on routine screening of healthy men because of the guidelines.

Still, the new recommendation may lead to more change than the USPSTF's 2008 guidelines against screening elderly men with PSA tests -- which another new study suggests did little to affect practice.

In the survey, "I was surprised that many clinicians did not expect the draft recommendations would affect their decision making, and there were many other barriers" to cutting back on screening, Pollack told Reuters Health.

That included doctors and nurses who said men expected to have a PSA test when they came into the office, as well as those who were afraid of getting sued if they didn't do the tests and a patient was later diagnosed with cancer.

All survey responders were from community sites affiliated with Johns Hopkins in Maryland, so it's unclear if their feelings reflect how doctors around the country feel about PSA testing, the researchers said.

Out of 124 doctors and nurse practitioners who filled out the study survey, half said they agreed or strongly agreed with the new draft recommendations against routine prostate cancer screening. Thirty-six percent disagreed or strongly disagreed, while the rest didn't have a strong opinion one way or the other.

Only a couple of clinicians said they would no longer offer PSA testing because of the USPSTF draft guidelines.

Among those who agreed with the recommendations, just over 40 percent said they wouldn't offer routine screening or would be much less likely to screen as a result of them, according to findings published in the Archives of Internal Medicine.

Challenging conventional wisdom
Researchers agreed convincing both doctors and patients that screening isn't always the way to go is a challenging next step.

"There's probably a very small benefit (to PSA testing) at best, and we know there's harm, but conventional wisdom is: early detection is always best," said Robert Volk, a professor of internal medicine who has studied prostate cancer screening at the M.D. Anderson Cancer Center in Houston.

"Physicians are concerned about patients' expectations. Patients typically want to be screened," Volk, who wasn't involved in the new study, told Reuters Health.

The fact that there's still some resistance to changing screening practices isn't surprising, said Dr. Michael LeFevre, co-chair of the USPSTF -- which also created a stir when it published guidelines recommending breast cancer screening starting at age 50, rather than 40 like some other organizations.

"We don't necessarily expect a dramatic turnaround in the way this test is being used," he told Reuters Health. "Change is not easy."

In another recent research letter, published Tuesday in the Journal of the American Medical Association, researchers found that 2008 guidelines from the USPSTF calling for no routine screening in men age 75 and up had led to little change.

Both before and after that guideline was released, 43 to 44 percent of older men surveyed said they'd had a PSA test recently, Dr. Sandip Prasad of the University of Chicago Medical Center and colleagues reported.

Videos or booklets that inform men about the potential benefits and harms of prostate cancer screening could help challenge the conventional screening wisdom and also protect doctors against being sued -- which is a very real concern given past cases, Volk said.

Pollack said adding screening-related alerts into electronic medical records -- which would inform doctors about the guidelines when they order a PSA test -- could also help guide doctors and patients in the right direction.