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Informed Decision - Clinician

Prostate Cancer Awareness Week ( has compiled information on the issue of. Informed Decision - Clinician.

Before testing a man for prostate cancer, help him make an informed decision by providing unbiased information. 

Prostate cancer is an important health concern for men. While a PSA test is not absolutely recommended for all men, its level can help stratify the risk for men for potentially lethal prostate cancer. Further, periodic PSA's can identify a meaningful rise that may reflect a clinically significant prostate cancer - one that may require treatment. *

Discuss objectively the potential risks as well as the potential benefits of testing for PSA; explore values with the patient that he may find important. Patient preference should guide the decision.

Studies indicate that there has been a reduction in mortality from prostate cancer and that a portion of that drop may be attributed to early detection of aggressive but curable disease; however, the PSA test is not foolproof.

Potential risks of testing include a diagnosis of prostate cancer that may not be clinically significant but which may cause anxiety, or which may lead the patient to choose immediate treatment when active surveillance may be more appropriate for him. Treatment in that scenario may cause unnecessary side effects such as the possibility of incontinence, urinary problems and/or sexual limitations.

Potential benefits of testing include the detection of potentially deadlly prostate cancer at a stage when it may be fully curable and treatable, and the peace of mind from knowing one's testing status.

Potential risks of not being tested may include an early stage potentially lethal prostate cancer that goes undetected and thus untreated, leading to serious disease and death.

Potential benefits of not being tested include avoidance of treatment for a prostate cancer that is not clinically significant and will not cause death, as well as avoidance of the adverse side effects that may occur with treatment.

Emphasize to the patient that a diagnosis of prostate cancer does not necessarily require treatment. For appropriate patients, Active Surveillance does not call for treatment until - and unless - the disease progresses or becomes clinically significant. This may require periodic blood tests and prostate biopsies to determine the need for future treatment.

When should you start talking to your patients about PSA Testing and which men should be tested?

Men likely to survive 10 years (based on co-morbilities, if any.)

A baseline PSA should be obtained at Age 40 (AUA PSA Best Practices Statement; 2009 update)> The PSA value at Age 40 will dictate when the patient should have a repeat PSA.

Men a higher risk, such as African-American men and those with a family history of prostate cancer, i.e., multiple family members with the disease before Age 65, may consider obtaining their first PSA at Age 35.

Some organizations, such as the American Cancer Society, recommend that a patient not have his first PSA until Age 50; other organizations, such as the National Alliance of State Prostate Cancer Coalitions and the California Prostate Cancer Coalition, recommend first PSA at Age 40 for men of average risk and at Age 35 for African-American men or those with a certain or an uncertain family history of prostate cancer.

Knowledge is power: Men should know their risk for potentially lethal prostate cancer and in doing so they will be empowered to make informed decisions regarding treatment choices (if any). By careful use of the PSA and other tests, an objectively informed man ma be able to have knowledge of his PSA and of his risk of clinically significant disease without the downside of automatically undergoing treatment that in come bases may not be necessary.

As a primary care physician, make sure you emphasize the need for a disconnect between a possible diagnosis of prostate cancer, and the need for treatment for that cancer. A man in consultation with his physician should decide whether he is an appropriate candidate for Active Surveillance/Watchful Waiting. For some it may be the right option; but it is not the right choice for some patients for whom treatment should not be delayed.

(There is a similar document to this one that has been written for lay people what you will probably want to give to your patients.)

*Current Guidelines suggest that a rise of .075 in one year should prompt a patient consultation with a urologist. You as the primary care physician and the urologist may co-manage and monitor the patient at risk for clinically significant prostate cancer.

 Source: California Prostate Cancer Coalition

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