For February’s CME identification I sat down and interviewed Dr. Ike Oguejiofor. Dr. Oguejiofor is a board certified physician Urologist on staff at Christ Hospital in the greater Chicago area.
OVERVIEW:
Dr. Oguejiofor enlightened me on an interesting discord in the current practice and perception of Prostate-Specific Antigen (PSA) screening by primary caregivers versus urologists. In 2012, the US Preventative Task Force released their recommendation that PSA based screening for prostate cancer should not be done at all at any age, reporting that “there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.”
Guidelines by the American Urological Association (AUA) generally agree, noting that PSA screening in men under age 40 years is not recommended and routine screening in men 40-54 who are at average risk is also no longer recommended. As well, they agree that men over 70 years of age should not be screened. However, for men 55 to 69 years of age the AUA recommends the following on their website:
“The decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, shared decision-making is recommended for men age 55 to 69 years that are considering PSA screening, and proceeding based on patients’ values and preferences. To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce over diagnosis and false positives.”
The way Dr. Oguejiofor translates this is that a risk/benefit analysis should be performed on a case by case basis. However, this can be confusing since our primary caregivers are now being told not to screen patients at all according the US Preventative Task Force Recommendations. So patients should be considered for revised or optional screening by their primary caregivers after an evaluation of their risk factors.
EDUCATIONAL/GAP ANALYSIS:
The Educational Gap identified by Dr. Oguejiofor is that early cases of prostate cancer may be missed in high risk patients, where screening may find elevated or PSA levels that are trending upwards, even if the level numbers are technically within the reference range. Dr. Oguejiofor strongly feels “age, family history and ethnicity must be taken into consideration while examining PSA values so early cases aren’t missed”.
LEARNING OBJECTIVES:
Learning objectives for CME on this topic must include the guidelines set forth by the AUA as well as the recommendations by the US Preventative Task Force. Dr. Oguejiofor strongly feels “age, family history and ethnicity must be taken into consideration while examining PSA values so early cases aren’t missed”. Identification of high risk patients over 55 years of age who may benefit from modified screening should be highlighted. High risk categories include:
Age – risk of prostate cancer rises rapidly after 50 years of age. About 6 in 10 cases are found in men over the age of 65.
Race – Prostate cancer occurrence is much in African-American men and in Caribbean men of African ancestry than in other races. African-American men are about wice as likely to die of prostate cancer than white men.
Family History – having a first relative with history of prostate cancer can more than double the risk of disease.
Genetic predisposition – a small number of cases of prostate cancer may be secondary to Inherited mutations of the BRCA1 or BRCA2 genes, or men who suffer from Lynch Syndrome.
Geography – Prostate cancer is more common in Australia, the Caribbean Islands, North America and Northwestern Europe. It less common Africa, Asia, Central America and South America.
POTENTIAL REFERENCES:
https://www.auanet.org/education/guidelines/prostate-cancer-detection.cfm
MeSH Medical 