Prostate cancer screening: A primary care survey

doi:10.4236/health.2010.210173

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Vol.2, No.10, 1179-1183 (2010) Health

doi:10.4236/health.2010.210173

Prostate cancer screening: a primary care survey

Samuel Deem1*, Brian DeFade1, Josh Lohri1, James P. Tierney1, Asmita Modak2, Mary Emmett2

1Department of Urology, Charleston Area Medical Center, Charleston, WV, USA; *Corresponding Author: deemsg@musc.edu

2Research & Statistics, CAMC Health Education & Research Institute, Charleston, WV, USA

Received 12 August 2010; revised 18 August 2010; accepted 25 August 2010.

ABSTRACT

Prostate cancer is the most common intrinsic

cancer in men and the 2nd most common cause

of cancer related death in men over fifty years of

age. The benefit of early screening for prostate

cancer is yet to be proven. Multiple organizati-

ons currently offer recommendations regarding

prostate cancer screening. Prostate Specific An-

tigen (PSA) testing was introduced into widesp-

read use in the late 80’s and its role in screening

is debatable. We surveyed by mail every primary

care physician in West Virginia who has a state

license. Results from 438 respondents indicated

that the American Cancer Society (ACS) guide-

lines were most commonly used and that PSA

testing does seem to be a good screening test.

We present the results and discuss the different

points of view regarding prostate cancer scree-

ning.

Keywords: Prostate; Cancer; Screening; PSA;

Guidelines; Survey

1. INTRODUCTION

Prostate cancer is the most common form of non-skin

cancer among men in the United States. It is the second

leading cause of cancer deaths in American men, after

lung cancer, and the sixth leading cause of death overall

for men in this country [1]. American men have a 1 in 6

chance of developing prostate cancer in their lifetime and

a 1 in 30 chance of dying from prostate cancer. Most of

the deaths from prostate cancer are related to advanced

disease that could have potentially been prevented with

better screening practices. However, multiple non-urolo-

gy driven groups propose less or no screening for pros-

tate cancer. Continuous advances have provided a new

understanding of the diagnosis, staging, and treatment of

metastatic and advanced prostate cancer and the poten-

tial benefits of early screening programs. Despite these

ongoing improvements, prostate cancer is unlike any ot-

her tumor, the natural history is that it will progress over

time but the unanswered question is over what period of

time.

Some prostate cancer would never have been detected

without screening using the PSA. Controversy exists be-

tween physicians worldwide about the pros and cons of

recommending early screening. Screening programs have

been shown to diagnose prostate cancer earlier but no

evidence currently can definitively prove a decrease in

mortality influenced by screening. Declining mortality

and observed trends of lower clinical and pathological

stages of the tumor where screening is common provides

inferential evidence that screening is possibly beneficial

[2]. It has been estimated that only 54% of men between

50 and 69 years of age have had a PSA test for screening

in the previous year [3].

Recently, a decrease in prostate cancer mortality was

seen in West Virginia and in the United States [4]. It is

not clear whether PSA-based screening was responsible

for this decrease but some studies have claimed a reduc-

tion in prostate cancer mortality through PSA-based sc-

reening [5,6]. Mortality rate due to prostate cancer is

steadily declining at a rate of 3.4% per year since 1990

indicating that screening is likely beneficial with the res-

ult being earlier diagnosis of an aggressive disease [7].

Current research is investigating whether screening for

prostate cancer is the primary factor leading to this redu-

ction in death caused by the disease, but results to date

have been conflicting.

The Prostate, Lung, Colorectal and Ovarian cancer sc-

reening trial (PLCO) is a randomized, prospective, mu-

lti-center trial in the U.S. designed to determine if pros-

tate cancer screening does alter mortality compared to no

screening [8]. Early results were recently published in

the New England Journal of Medicine (NEJM) showing

no early benefit of screening for prostate cancer seen at 7

to 10 years follow-up. The results and the limitations of

the study have been discussed extensively in recent liter-

ature. Some of the criticisms include the length of foll-

ow-up being too short to show a survival benefit because

S. Deem et al. / Health 2 (2010) 1179-1183

1180

prostate cancer can be an indolent disease taking several

years to become aggressive. The trial included patients

in the non-screening arm that were previously screened

prior to the trial or were screened during the trial, both of

which would include men with a lower risk of develop-

ing cancer during the trial. We all await the final results

of the trial once long term data has been collected [9].

Results of another trial, the European Randomized

Study for Screening of Prostate Cancer (ERSPC), were

published in the same issue of NEJM. The authors repo-

rted that screening reduced the rate of prostate cancer

death by 20 percent but was associated with a higher rate

of over-diagnosis. Several criticisms of this study have

been discussed and the contrast between the two trials is

alarming. Further development of the data is necessary

to draw any conclusions from either trial [10].

Another area of research interest includes both patie-

nts and health care providers’ knowledge and awareness

of prostate cancer screening. These projects will further

the efforts to develop and deliver appropriate public hea-

lth strategies for prostate cancer, and will improve the sh-

aring of screening-related information between providers

and their patients [11]. Until further data exists, we must

rely on the best evidence available, which currently wo-

uld recommend early screening for prostate cancer in a

select patient group only after a thorough discussion of

the potential risks and benefits of screening with the pa-

tient. Educating patients about all options for treatment

of prostate cancer including active surveillance may help

avoid the unnecessary treatment of some cancers while

still screening to find the aggressive types.

Our objectives with this study were first to determine

the current screening practices of primary care physic-

ians in one state (West Virginia) and then to discuss

what current best evidence would suggest.

2. METHODS

This study was approved by the Institutional Review Bo-

ard at Charleston Area Medical Center. We present the

data that was collected from a mail survey of all physi-

cians identified as primary care practitioners through the

West Virginia Board of Medicine and the West Virginia

Board of Osteopathy. Questionnaires were mailed out in

March of 2008 with a follow-up mailing completed in

May of 2008. The questionnaire consisted of thirteen

multiple-choice questions using a standardized data col-

lection form. The questions focused on the physicians

personal practice preferences and their attitudes toward

prostate cancer screening and guidelines including the

use of PSA and digital rectal examination (DRE) for this

screening.

Statistical anaylysis was performed by CAMC Health

Education and Research Institute, Center for Health Serv-

ices and Outcomes Research. Descriptive statistics were

used. Chi squared/Fisher’s exact tests where appropriate

were used at 95% level of significance for cross tabula-

tion analysis after combining different questions. Analy-

sis was done using SAS 9.1.3.

3. RESULTS

Out of a total of one-thousand five hundred and thirty-

six (1536) questionnaires a total of 442 physicians re-

sponded to the survey. Of these, 58 had either an incor-

rect address or reported that they had retired from gen-

eral practice or practiced in a select medical specialty.

Four additional responses came in after the data were

calculated and therefore are not included in the results.

Our results are based on 380 completed questionnaires.

The guideline cited as the most used was the Ameri-

can Cancer Society (ACS) guidelines with 187 (56.5%)

respondents using this in their current practice. Only 9

(2.72%) respondents currently used the National Compr-

ehensive Cancer Network (NCCN) guidelines for pros-

tate cancer screening. Table 1 lists each guideline and

shows the percentages of respondents who indicated that

they used them. This table illustrates the percentage of

respondents who feel that PSA is a useful screening tool

for prostate cancer and compares this response to which

guideline they use. When asked about familiarity with

NCCN guidelines in regards to prostate cancer, 157

(42.9%) of the respondents were not at all familiar and

33 (9.02%) did not know about the NCCN guidelines.

Only 4 of the 33 physicians who were very familiar with

the guidelines actually based their screening on them.

Table 1. Distribution of physicians using each guideline and

the response to “Is PSA a useful screening test?” based on the

guideline used.

Is PSA useful

Guidelines

Undecided No Yes

Total

American

Cancer Society

(14.68%)

(2.14%)

132

(40.37%)

187

(57.19%)

American Urological

Association

(3.06%)

(0.61%)

(9.48%)

(13.15%)

Center for

Disease Control

(2.45%)

(0.31%)

(2.45%)

(5.20%)

National Comprehensive

Cancer Network

(0.61%)

(0.31%)

(1.53%)

(2.45%)

Other/(USPSTF) 26

(7.95%)

(3.98%)

(10.09%)

(22.02%)

Total 94

(28.75%)

(7.34%)

209

(63.91%)

327

(100.0%)

S. Deem et al. / Health 2 (2010) 1179-1183

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Three hundred and forty-seven (93.53%) clinicians

reported either yes or it depends when asked if they

routinely screen all men over the age of 50 for prostate

cancer. Two hundred and fifty four (68.65%) respon-

dents routinely performed a digital rectal examination

(DRE) and 308 (81.91%) routinely checked a Prostate

Specific Antigen (PSA) test in all men over the age of 50.

Figure 1 shows the results of using either a DRE or PSA

or both by those who routinely screen for prostate cancer

in men after the age of 50.

Two hundred and forty-five (245) (65.51%) clinicians

felt that the PSA is a useful screening tool for diagnosing

prostate cancer while an additional 105 (28.07%) were

uncertain. Urology consultation was most commonly

advised when a PSA value of greater than 4 was found

with 218 (59.24%) in agreement. We found that 145

(39.84%) physicians who consider the PSA to be a use-

ful screening test also feel that a PSA level greater than

4 is when to suggest a Urology consultation. The P-value

was found to be 0.0423, which means that there is a sta-

tistically significant difference between physicians con-

sidering PSA as a useful screening tool and their opinion

about advisable PSA level for referral at 95% level of

significance.

Physicians answered that age rather than guidelines is

the most common reason for recommending prostate

cancer screening as seen in Figure 2. Most physicians

(70%) were unaware of the current rise in prostate can-

cer in African American men but 57% would be more

likely to screen for prostate cancer in a 40 year old male

if he was African American. Figure 3 shows that 55% of

clinicians answered either no or that they are unsure if

prostate cancer screening decreases mortality or morbid-

ity of prostate cancer. And finally, 243 (65.7%) physi-

cians felt that PSA was a useful screening test.

*The above percentage represents out of 304 physicians who routinely sc-

reen men for prostate cancer each year past the age of 50.

Figure 1. Distribution of PSA and DRE screening.

Figure 2. Most common reason cited for performing prostate

cancer screening.

Figure 3. Does screening for prostate cancer decrease mortal-

ity or morbidity of men with prostate cancer?

4. DISCUSSION

The NCCN practice guidelines in oncology as well as

the American Urological Association (AUA) and the

ACS all suggest that a baseline PSA level be offered at

age 50 in addition to a baseline digital rectal exam after

a discussion of the risks and benefits of early screening

[2,3,12]. A 1993 study in Missouri by Lawson and col-

leagues found that most primary care physicians felt that

the PSA test was an important screening test for prostate

cancer [13]. The results from Missouri are similar to

West Virginia but the PSA test as a screening tool is still

used with hesitancy by many. The American Academy

of Family Physicians (AAFP), National Institute of

Health (NIH) and the U.S. Preventive Services Task

Force take a position against early prostate cancer

screening [14-16]. The lack of literature to support a

decrease in mortality or morbidity as well as absence of

a treatment option that routinely causes no harm are the

primary concerns voiced by the groups.

The NCCN is currently one of the most trusted reso-

S. Deem et al. / Health 2 (2010) 1179-1183

1182

urces available to practitioners for established guidelines

regarding screening, diagnosing and treating various typ-

es of malignancy. They provide evidence based medic-

ine reviews of the current literature and guidelines for

multiple cancers. Twenty-one of the most respected ca-

ncer centers in the world meet frequently to discuss the

literature and establish these guidelines. They are avail-

able at no costs to anyone who can access the Internet

(http:www.nccn.org) and are reported in the urology

literature. The NCCN recommends screening for pros-

tate cancer to include annual DRE and PSA in all men

after the age of 50 after discussing the risks and benefits

of screening with the patient. High risks groups includ-

ing African American males and patients with a family

history of a first degree relative with prostate cancer

should begin screening at age 40. The ACS guidelines

are available online and they recommend offering

screening similar to the NCCN guidelines in a patient

with life expectancy greater than 10 years [2,3].

Performing a DRE prior to checking a PSA level has

been proven to be insignificant. If there is no evidence of

recent urinary retention or catheterization, acute prostati-

tis, prostate needle biopsy, or vigorous therapy that wo-

uld include manipulation of the gland (i.e., colonoscopy

or anal intercourse) then performing a DRE prior to ch-

ecking the PSA level should not affect the results [17].

Patient age and life expectancy, co-morbidities, and his-

tory of prostate enlargement or an elevated PSA should

all be considered when determining whether or not to

obtain urology consultation. When in doubt it is always

best to proceed with specialty inclusion in the decision

planning. PSA velocity is another method of determining

a need for further intervention. Presently a rise in PSA of

> 0.75 ng/ml in one year is an indication for prostate

biopsy in normal circumstances. The NCCN now advo-

cates lowering this threshold to > 0.35 ng/ml in patients

with a PSA level < 4(2).

The only accepted risk factors for prostate cancer are

increased age, African American race, and family histo-

ry, which are not modifiable. The American Cancer Soc-

iety recommends a diet low in saturated fat and red meat.

Selenium and Vitamin E have been reviewed as potential

prevention strategies, however, recent literature showed

no benefit in prostate cancer prevention [18].

5-alpha reductase inhibitors (Finasteride and Dutas-

teride) have been advocated as a potential chemopreven-

tion therapy for prostate cancer. The Prostate Cancer

Prevention Trial (PCPT) randomized men into receiving

either Finasteride or placebo and performed biopsy when

the PSA rose to a level of 4 or greater or an abnormal di-

gital rectal exam was found. Patients were followed for

seven years and a 24.8 percent reduction in the preva-

lence of prostate cancer was found in the Finasteride arm.

However, there was an increase in the number of high

risk cancers found in the Finasteride arm [19]. The Re-

duction by Dutasteride of prostate Cancer Events (RE-

DUCE) trial, showed a 22.8 percent relative reduction in

prostate cancer in the Dutasteride arm indicating effecti-

veness in chemoprevention of prostate cancer. The AUA

and the American Society of Clinical Oncology released

guidelines on chemoprevention of prostate cancer rec-

ommending a discussion with men who met the criteria

on the risks and potential benefits of 5-alpha reductase

inhibitors for prevention of prostate cancer [20].

Aside from these recommendations there are no other

modifiable risks that have been established in the current

literature. This is the basis for why early screening is co-

nsidered by most Urology physicians to be such an obv-

ious recommendation. We can only hope to diagnose the

more aggressive tumors early before they have spread and

allow better control and decreased mortality from this

peculiar disease. Our goal in supporting prostate cancer

screening, as in other types of cancer screening, is to of-

fer everyone the opportunity to have their disease diag-

nosed before it is problematic.

Some limitations of this survey are that it may not be

a representative sample of the primary care physician

population in the U.S. Only 25% of the surveys were re-

turned and some specialty-trained physicians could have

returned their results. The length of time since residency

training could affect the method of prostate cancer scr-

eening to some degree and this was not categorized by

the survey.

Prostate cancer remains an elusive disease with an un-

predictable course causing controversy in screening and

treatment recommendations. Screening for prostate can-

cer will likely be controversial for many years to come.

However, the decline in prostate cancer mortality in the

PSA era can not be ignored. Identification of patients

with prostate cancer that may benefit from early treatm-

ent can only be achieved by following the best evidence

we have to date which would support at least some role

for early prostate cancer screening. Collaboration amon-

gst the various organizations providing guidelines will

be necessary to unify the recommendations and standar-

dize screening to improve the effectiveness of screening

long term.

5. CONCLUSIONS

Primary care physicians currently have a broad range of

commitment to prostate cancer screening which is in ac-

cordance with the lack of quality studies to confirm its

efficacy in decreasing mortality and morbidity in the cu-

rrent literature. The diversity amongst the various guide-

lines and paucity of evidence to support screening cer-

S. Deem et al. / Health 2 (2010) 1179-1183

118

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tainly makes the task of providing uniform screening rec-

ommendations difficult. Universal commitment to prost-

ate cancer screening will only be adopted when all guid-

eline panels assimilate and the literature can support th-

em. But with the lack of quality, long-term, randomized

controlled trials to guide the recommendations, we will

likely continue with our current individual best practices

based solely on practice preferences and individual atti-

tudes toward screening.

6. ACKNOWLEDGEMENTS

This study was supported by the CAMC Foundation, Sarah and Pa-

uline Maier Foundation and CAMC Institute, Inc. of Charleston, WV.

We would like to thank Suzanne Kemper, MPH for all of her help with

this project.

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