Correspondence

Screening for Prostate Cancer

N Engl J Med 1994; 330:220-221January 20, 1994

Article

To the Editor:

Guidelines recently published by the American Cancer Society1 recommend that men over the age of 50 have an annual digital rectal examination and a prostate-specific-antigen assay. These recommendations are problematic. Other expert panels have not issued such guidelines2. Investigators from the American Cancer Society have stated, with regard to prostate cancer, “no randomized, controlled study has ever demonstrated disease-specific mortality reduction from any test or procedure”3.

The American Cancer Society has issued screening guidelines that were subsequently retracted. These guidelines included the use of chest films to screen smokers for lung cancer,4 annual sigmoidoscopy for adults over the age of 40,5 and mammography for women between the ages of 35 and 396. These recommendations were discontinued in 1980, 1980, and 1992, respectively. The society has stated that its guidelines “are not recommendations for public programs of mass screening.” Nevertheless, these guidelines have a substantial effect on the behavior of physicians7.

The work of the American Cancer Society has been of incalculable benefit in oncology research and in increasing public awareness of cancer. I am concerned, however, that unnecessary use of resources and other harmful consequences may have resulted from the retracted guidelines. A similar situation may develop if future research invalidates the current guidelines for prostate-cancer screening. It may be a disservice for highly regarded groups such as the American Cancer Society to issue screening guidelines before there is adequate supporting evidence.

Robert G. Badgett, M.D.
University of Texas Health Science Center at San Antonio, San Antonio, TX 78284-7879

7 References

1. 1

   Mettlin C, Jones G, Averette H, Gusberg SB, Murphy GP. Defining and updating the American Cancer Society guidelines for the cancer-related checkup: prostate and endometrial cancers. CA Cancer J Clin 1993;43:42-46
   CrossRef | Web of Science | Medline

2. 2

   Garnick MB. Prostate cancer: screening, diagnosis, and management. Ann Intern Med 1993;118:804-818
   Web of Science | Medline

3. 3

   Littrup PJ, Goodman AC, Mettlin CJ. The benefit and cost of prostate cancer early detection. CA Cancer J Clin 1993;43:134-149
   CrossRef | Web of Science | Medline

4. 4

   Cancer of the lungCA Cancer J Clin 1980;30:199-207
   CrossRef

5. 5

   Cancer of the colon and rectumCA Cancer J Clin 1980;30:208-215
   CrossRef

6. 6

   Update January 1992: the American Cancer Society guidelines for the cancer-related checkup. CA Cancer J Clin 1992;42:44-44
   CrossRef | Web of Science | Medline

7. 7

   1989 Survey of physicians' attitudes and practices in early cancer detectionCA Cancer J Clin 1990;40:77-101
   CrossRef | Web of Science | Medline

Author/Editor Response

The above letter was referred to the American Cancer Society, which offers the following reply:

To the Editor: Dr. Badgett raises important issues with respect to guidelines for cancer detection -- i.e., how sound is the scientific evidence on which the guidelines are based, and are they permanently appropriate?

The American Cancer Society creates its guidelines on the basis of the available data, which are constantly evolving. The data gathered before the formulation of cancer-screening guidelines include the extent of the disease burden, identifiable risk factors, the accuracy of the test under consideration, its acceptability to patients, its feasibility, the cost of the test, and the soundness of the evidence that earlier intervention is medically effective and involves minimal risk for the patient.

Dr. Badgett points up the dilemma of issuing guidelines in the absence of data from randomized clinical trials. Data from these sources would be ideal, but unfortunately they are also rare. Surveys show that over 70 percent of primary care physicians in the United States were using screening tests to detect prostate cancer before the issuance of the American Cancer Society guidelines. These guidelines are intended to assist in case finding after discussion between the patient and the physician. The immediate needs of patients and providers require that we give careful consideration to methods and data from study designs other than randomized clinical trials and note their limitations when appropriate.

The American Cancer Society continuously reviews new data to ensure that its guidelines reflect the most current knowledge in a particular field. As Dr. Badgett points out, the emergence of new data often results in changes in, or even the abolishment of, certain guidelines. That is an accepted result of new medical knowledge.

Reginald C.S. Ho, M.D.
American Cancer Society, Atlanta, GA 30329-4251