For the first time, the American Urological Assocation is discouraging many men from having prostate cancer screening, and encouraging those who do to consider the harms as well as benefits.
In guidelines issued Friday, the association recommends against routine PSA testing for men before age 40 or after age 70, men of any age with a life expectancy of less than a decade, or average-risk men ages 40 to 54.
Men 55 to 69, and younger men who are at high risk because of their race or family history, should go through "shared decision making" with their doctors to weigh the pros and cons of screening, and their individual values, the guidelines say.
The advice puts the urologists' group - traditionally fervent defenders of the PSA test - more in step with the U.S. Preventive Services Task Force.
A year ago, that influential federal panel said men should abandon routine PSA testing because early detection saves few if any lives, most prostate tumors would never become life-threatening if left alone, and treatment often causes sexual and urinary problems.
It remains to be seen whether rank and file urologists will embrace the guidelines, developed by a committee that spent two years reviewing the scientific evidence. Even if clinicians get on board, shared decision making - a strategy for helping patients choose from several prudent options - can be time-consuming. And some patients would rather just be told what to do.
"I think urologists do what's in the best interests of their patients," said H. Ballentine Carter, the urological oncologist who led the guidelines committee. "Yes, there will be differences of opinion, but the members of the AUA will recognize that a one-size-fits-all approach is not the way to go right now."
The directive doesn't address the practice of offering free PSA testing at public events, but Carter said it is frowned upon.
"It is very, very clear that the panel discourages the use of the PSA test outside the context of shared decision making," he said. "Health fairs and community organizations should not do it."
The nonprofit Prostate Conditions Education Council in Colorado disagrees. As "one of the most successful health screening projects in the world," it brings free or low-cost screenings to 125,000 men a year.
"I call it early detection, not mass screening," said urological oncologist E. David Crawford, chair of the council. "You can call it mass screening; I think it's case-finding."
"It's a money machine," said Richard J. Ablin, 72, an Arizona immunobiologist and a harsh critic of screening. "Without this test, there would be a significant financial impact on the urological industry."
In 1970, Ablin discovered the prostate-specific antigen, a blood protein that can surge with benign as well as malignant prostate gland changes. In 1986, the government approved the PSA test to monitor cancer patients for recurrence after treatment, a use Ablin endorses. But medical and patient groups promoted the test for screening.
The test "is not cancer-specific, there is no reliable PSA level for diagnosis, and it can't distinguish between indolent and aggressive cancers," Ablin said. "But once you take a psychologically healthy man and...tell him he has cancer, his inclination is to cut it out."
Early detection has dramatically reduced the proportion of men who have metastatic disease at the time of diagnosis, from 70 percent in the early 1990s to 3 percent now.
But does that translate to lives saved? The best studies offer different answers. A major U.S. screening study found prostate cancer death rates were the same among screened and unscreened men after 13 years. A major European trial found 1 fewer prostate cancer death per 1,000 men screened over 11 years.
However, that European study also found that 210 out of every 1,000 screened men were sent for a biopsy, fewer than half of whom were found to have cancer. Of 99 who wound up having surgery or other treatment, 40 became incontinent or impotent.
Numerous companies have developed tests intended to improve - but not replace - the PSA test. These assays clarify biopsy results, indicate whether to repeat the biopsy, or assess whether the cancer can be monitored rather than treated.
But the best combinations of tests - not to mention the added costs - are far from clear.
"We've come a long way since 1989," Crawford said. "Basically, the whole controversy comes down to this: We diagnose 240,000 men a year; 30,000 die. How do we focus on that group at risk of dying?"