Dr. Andriole responds to the American College of Physicians' Guidelines on PCa Screeening

This past summer, the American College of Physicians released a clinical guideline on prostate cancer
screening with two specific recommendations-- "Rather than screening all men for prostate cancer as a
matter of routine, physicians should describe the potential benefits and known harms of screening, diagnosis,
and treatment; listen to the patient's concern; and then individualize the decision to screen" and "The College
strongly recommends that physicians help enroll eligible men in ongoing clinical studies and before any testing
occurs, patients should be fully informed about" the known facts concerning prostate cancer screening and
treatment. Beginning on page 10, Gerald Andriole, M.D., of Washington University, writes that the approach
fostered by the first recommendation in the guideline would result in selective application of screening and may
not actually result in screening the highest risk populations because some patients at highest risk for prostate
cancer may have little time or an aversion to the screening examinations, or become bewildered by the
uncertainty and, therefore, choose to do nothing rather than to expose themselves to the projected harms of
proceeding. Regarding the second recommendation, Dr. Andriole points out that the ACP endorses the
Prostate, Lung, Colon and Ovarian cancer screening trial that is being performed at 10 selected sites and the
Prostate Cancer Intervention Versus Observation Trial. "Even if so inclined to allow his health choices to be
made by the flip of a coin, how likely is it that a given patient will have geographic access to a center
performing these studies?" he asks. He states that a more reasonable approach is for a physician to obtain the
best information on a specific individual's risk for prostate cancer--family history, digital rectal exam, PSA
test--and to review the potential significance of these findings with the patient. "This approach seems far more
feasible than that endorsed by the American College of Physicians, as it bases the discussion with the patient
on specific baseline information rather than on general population-wide averages, and then allows patients and
physicians to truly individualize further management and treatment," Dr. Andriole concludes.

Dr. Albertsen Responds

In defending the ACP guideline, Peter C. Albertsen, M.D., of the University of Connecticut Health
Center, writes beginning on page 26 that detractors from prostate cancer screening remind us that little
evidence is available to support the contention that early detection leads to decreased mortality from
prostate cancer. Dr. Albertsen goes on to point out that age adjusted mortality rates from prostate cancer
have not declined significantly during the last few years, that no one knows the natural history of PSA
identified prostate cancer because PSA testing is still relatively recent when judged against the natural
progression of this chronic disease, that prostate cancer screening can lead to significant morbidity from
treatment, and that one-half of the men with newly diagnosed prostate cancer fall in the age category where
the risk-to-benefit ratio from screening and treatment becomes quite marginal compared with a strategy based
upon treatment of symptomatic disease with antiandrogen therapy. Dr. Albertsen concludes by writing that "In
light of the uncertainty surrounding the benefit of prostate cancer screening and in view of the evidence of
potential harm, how could one argue against a recommendation that calls for patient education and selective
use of serum PSA testing?" and "randomized clinical trials can provide answers to many of our questions but
only if physicians encourage patients to enroll."

November/December 1997 AUA News