Volume 117, Issue 10 , Pages 796-798, 15 November 2004
Reducing PSAnxiety: The importance of noninvasive chronic disease management in prostate cancer detection and treatment
Article Outline
Current practice patterns suggest that screening for prostate cancer is a popular strategy despite its uncertain effectiveness. Three-quarters of men over the age of 50 years have received a PSA test sometime in their life. Fifty-seven percent of these men have received PSA testing within the past year, including men aged 80 years and older. This percentage is higher than for colorectal cancer, a test with proven efficacy for reducing cancer-related death (1).
In late 2002, the United States Preventive Services Task Force published a systematic review of the existing evidence regarding screening for prostate cancer and concluded that clinicians should not screen without first discussing with patients the potential but uncertain benefits and possible harms of screening (2). Since the publication of these recommendations, clinicians and health care systems have been struggling with how best to integrate counseling about prostate cancer screening into the busy practice setting. Given the complexity of the information to be communicated and the societal and systematic biases toward screening, producing well-informed decisions about prostate cancer screening often requires considerable time and effort (3, 4).
The article by McNaughton-Collins and colleagues in this issue of The American Journal of Medicine examines the short-term psychological consequences of “suspicious” prostate cancer screening tests and suggests that the task may be even more challenging than previously thought (5). Echoing results from an extensive literature on the psychological consequences of screening for breast and cervical cancer, as well as the few previous studies examining psychological distress associated with screening for prostate cancer (6, 7), McNaughton-Collins and colleagues found that elevated cancer-related anxiety associated with abnormal prostate-specific antigen (PSA) results persists even after a diagnostic prostate biopsy reveals benign results. Incorporating information about this human cost of screening into discussions about the benefits and harms of PSA testing, as suggested by the authors, only adds to the already complex nature of counseling about screening.
The implications of adverse psychological consequences associated with suspicious PSA levels in the ongoing debate about prostate cancer screening are potentially quite important. Psychological sequelae and concomitant increases in health care costs are possible for certain subgroups of patients (8, 9, 10), and, based on estimates derived for mammography (which has a similar false positive rate) (11), more than half of men screened annually will receive at least one false positive PSA result over the course of their lifetime. Although we agree with the recommendation made by McNaughton-Collins and colleagues, the implications for practice are potentially problematic. Given that effective counseling about the uncertainty surrounding screening for prostate cancer is difficult and time consuming, most of the anxiety that is associated with false positive screening results is transient and subclinical (12) and that proactive attempts to reduce screening-related anxiety might do more harm than good (13), one might question whether this issue is worth proactive attention. Indeed, one could argue that screening despite uncertain evidence is reasonable because patients prefer to be screened (14), there are few incentives for providers not to honor this preference (4), and current practice does not encourage the detailed discussions needed to counsel patients adequately about the potential merits of not screening. Despite these obstacles, we assert that counseling is likely to be preferable to routine testing for reasons described below.
Why counsel before screening?
One of the most commonly cited reasons patients provide for being screened for cancer is to achieve “peace of mind.” Unfortunately, the traditionally accepted “normal” range of <4.0 ng/mL is not likely to provide reassurance for patients or physicians in the future. This is because recent studies suggest that the prevalence of prostate cancer among men aged 62 to 91 years with serial PSA levels below 4.0 ng/mL is 15.2% (15) and that approximately 25% of all men with PSA values between 2.1 and 4.0 ng/mL have prostate cancer. If doctors offer a baseline PSA beginning at age 40 and consider biopsies for men with PSA readings above 2.5 ng/mL, the number of men labeled as having an “abnormal” PSA will double and the number who are recommended for prostate biopsy and eventually labeled as having prostate cancer will increase (2). As a result, patient-related anxiety around PSA testing is likely to increase, rather than decrease.
In addition, even a prostate biopsy that finds no evidence of malignancy in the setting of a PSA level of 4 ng/mL or higher is not sufficiently reassuring to many patients. One quarter of men in the authors’ biopsy group reported undergoing three or more procedures, and nearly all reported that they would undergo another biopsy if recommended by their physician. Although adverse effects of prostate biopsy are generally mild and resolve within weeks (16), they are common and increase with a greater number of core specimens. Unlike prior practices of obtaining six prostate core specimens, 12 cores of biopsies are now commonly obtained, and “saturation biopsy” techniques yield 40 or more prostate cores. This has led to chance detection of many small volume tumors. PSA levels now correlate with prostate weight (i.e., benign prostatic enlargement) but not prostate cancer, even among patients undergoing radical prostatectomy. Thus, over 50% of prostate cancers detected due to abnormal PSA results are found serendipitously (i.e., not the cause of the PSA abnormality that led to the biopsy), and the vast majority of prostate cancers remain asymptomatic if left untreated (17).
In the absence of clear-cut evidence of effectiveness, not screening may be a better alternative to the cycle of increased testing and treatment. The concept of noninvasive chronic disease management incorporates the dictum of “primum non nocere” or “First do no harm” (18). This approach is neither nihilistic nor uncaring; it involves a proactive discussion to highlight the use of diagnostic tests and treatments that are most likely to improve length and quality of life while minimizing adverse effects and unnecessary costs. It provides compassionate care that can decrease anxiety and yield superior outcomes to the overwhelming majority of patients.
The concept of noninvasive chronic disease management is increasingly important in providing quality care to elderly patients, those with comorbid conditions, or those preferring to avoid the risks (including psychologic distress) associated with testing and treatment of a large and increasingly identified reservoir of asymptomatic conditions that, if left undetected, are unlikely to cause morbidity or mortality (i.e., pseudodisease) (19). The role of PSA testing in prostate cancer detection and treatment is one example in which noninvasive chronic disease management may provide superior health outcomes compared with escalating testing and treatment.
The concepts of noninvasive chronic disease management are commonly used in daily practice and can be incorporated into shared decision making processes. Because a provider’s recommendation (or lack thereof) is the strongest predictor of cancer screening behavior, incorporation of these concepts into primary care settings will undoubtedly influence the patients’ attitudes and decisions about screening.
Recent reports provide estimates of the outcomes of noninvasive chronic disease management compared with aggressive intervention for prostate cancer. Based on autopsy series, the prevalence of prostate cancer increases with age and is 15% to 80% in men 60 to 90 years of age (20). The lifetime risk of death from prostate cancer is 3%, and the lifetime risk of a diagnosis of prostate cancer is 16%. Using 1988 to 1992 mortality rates for Quebec and data on PSA screening, only 16 of 100 detected prostate cases represented potentially lethal cancers (20). Thus, the prevalence of overdetection (i.e., pseudodisease) is at least 80% of PSA detected cases. Lowering suspicious PSA thresholds and increasing the frequency or number of biopsy specimens obtained is likely to increase the detection and treatment of pseudodisease. A man’s lifetime risk of clinical prostate cancer may approach what is found in autopsy series.
Johansson and colleagues reported on the long-term outcomes (mean follow-up of 21 years) of men whose clinically localized prostate cancer was detected prior to PSA testing and who did not receive intervention with surgery or radiation therapy (21). Of the original 223 subjects, 39 (17%) experienced generalized disease and 16% died from prostate cancer. The authors used short-term results from the Scandinavian Prostate Cancer Group-4 (SPCG-4) randomized trial that compared radical prostatectomy with watchful waiting to estimate that 8% might have experienced a survival benefit with early intervention; the remaining 92% would likely have better outcomes with noninvasive chronic disease management (22). In the SPCG-4 study, surgery compared with watchful waiting reduced the number of deaths attributed to prostate cancer by about 4 in 100, and the number who developed metastatic disease by about 5 in 100, but overall survival and quality of life were similar in the two groups (22). Men who received radical prostatectomy had higher rates of erectile dysfunction and urinary leakage but lower rates of weak urinary stream. Compared with physical examination, PSA testing increases the detection of pseudodisease and advances the time of diagnosis by 10 years or more (20). Therefore, benefits in prostate cancer survival due to surgery are likely limited to a small percentage of men with PSA-detected cancer and would not be seen until 25 to 30 years following diagnosis.
D’Amico and colleagues found a 10% overall survival benefit at 5 years in men with high-risk, clinically localized prostate cancer (defined by a PSA of at least 10 ng/mL, or a Gleason score of at least 7, or radiographic evidence of extraprostatic disease) randomized to radiation therapy plus 6 months of androgen suppression compared with radiation therapy plus delayed androgen suppression. This group comprises a small percentage of patients detected (23). Similar findings have been reported in men with more advanced disease. It is not known if radiation improves survival compared with short-term androgen suppression alone or if it should be reserved for patients who develop advanced disease (23). Therefore, incorporation of noninvasive chronic disease management may spare many men the adverse effects of early radiation therapy.
In summary, the results reported by McNaughton-Collins highlight the important and growing concerns related to testing for prostate cancer. As long as the evidence remains uncertain, anxiety is unlikely to be reduced by screening more men. Although it may be the path of greater resistance, we will better serve our patients by acknowledging that screening for prostate cancer, although an attractive option for many, is not the best option for all. We should take the time and effort needed to assert this point in decisions made jointly with patients.
Acknowledgment
The authors thank Debra McKeehen, MS, for her comments and assistance in preparation of this manuscript.
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PII: S0002-9343(04)00624-2
doi:10.1016/j.amjmed.2004.10.002
© 2004 Elsevier Inc. All rights reserved.
Volume 117, Issue 10 , Pages 796-798, 15 November 2004
