FNPs, do you do prostate exams?

anh06005, MSN, APRN, NP · Apr 8, 2015

Yes I have noticed lots of conflicting guidelines also. I plan on doing what one of my collaborating doctors does:

I believe it's yearly PSA's as long as the patient's wants to do that. If a patient asks about a rectal exam he is completely honest: he will do one without any issue but since it's not something we do often he may not pick up on subtle changes. Patient's often understand this limitation from primary care providers. If they are truly concerned or have a worrysome family history of prostate CA they may be offered a uro consult...especially if they are having any issues or have an elevated PSA.

It's difficult to be an expert at everything. Especially if it's something you only see/do a time or two a year (if that).

allnurses Guide · Apr 9, 2015

I explain the risks and benefits of both annual PSA screening vs DRE examination. I will often screen via PSA, if elevated then do a DRE. Based on the DRE I can either refer immediately to urology or wait 6 weeks and re-screen after reinforcing education about common causes for false positive PSAs.

Sent from my iPhone.

fnpwill · Apr 12, 2015

I am a urology nurse practitioner in New York and I do prostate exams. The prostate exam in part of the male physical exam. Especially forr males over the age 45 and with patients exhibiting signs of BPH.

URONP · Aug 31, 2016

Yes, you should do prostate exams. Like anything else, you get accustomed to feeling what is normal and what is not. I do several a day as a urology NP. The PSA, and exam should go hand in hand. How often these are done depends on the patient's situation. A normal exam, combined with a normal range PSA - usually equates to just annual monitoring. Suspicious exam, with a rising PSA, you will monitor more closely, could be as often as every 3 - 6 months.

A urology NP organization is being developed. I will keep you posted as they are up and running. The goals will be education on subjects, such as those you are asking about now.

YoutubeTheNP · Sep 1, 2016

I'm surprised to see a lot of Uro NPs checking PSA. According to Final Update Summary: Prostate Cancer: Screening - US Preventive Services Task Force

it is not recommended. What guidelines do you use to check routine/annual PSA?

I agree with the physical exam, annually with physical, men over 45, if they elect.

allnurses Guide · Sep 1, 2016

I'm surprised to see a lot of Uro NPs checking PSA. According to Final Update Summary: Prostate Cancer: Screening - US Preventive Services Task Force
it is not recommended. What guidelines do you use to check routine/annual PSA?
I agree with the physical exam, annually with physical, men over 45, if they elect.

"The American Cancer Society (ACS) emphasizes the need for involving men in the decision whether to screen for prostate cancer. Men need to have sufficient information regarding the risks and benefits of screening and treatment to make an informed and shared decision; providing them with a decision aid may facilitate the decision-making process [46]. For men who decide to be screened, the ACS recommends PSA testing with or without DRE for average-risk men beginning at 50 years of age. Screening should not be offered to men with a life expectancy less than 10 years. Men whose initial PSA level is greater than or equal to 2.5 ng/mL should undergo annual testing; men with a lower initial level can be tested every two years. The guidelines also recommend beginning screening discussions at age 40 to 45 in patients at high-risk of developing prostate cancer (eg, black men and men with a first-degree relative with prostate cancer diagnosed before age 65). The guideline also recommends keeping the biopsy referral threshold at 4.0 ng/mL. However, for men with PSA levels from 2.5 to 4.0ng/mL, the guideline encourages individualized decision making and risk assessment (http://deb.uthscsa.edu/URORiskCalc/Pages/uroriskcalc.jsp), which can include age, race, family history, digital rectal examination findings, previous biopsy results, and use of five alpha-reductase inhibitors.

â—The American Urological Association (AUA) updated its guideline in 2013 [172]. The AUA recommends against screening men younger than 40, and also does not recommend routine screening for average-risk men ages 40 to 54, men older than 70, or men with a life expectancy of less than 10 to 15 years. Decisions should be individualized for higher-risk men ages 40 to 54, and the AUA noted that some men over age 70 in excellent health might benefit from screening. The AUA strongly recommends shared decision making in deciding on PSA screening in men ages 55 to 69. The guideline panel could find no evidence to support the continued use of DRE as a first-line method of screening. The AUA stated that a screening interval of two years for men who choose screening may be preferred to annual screening and that screening intervals can be individualized based on baseline PSA level. The guideline noted the lack of evidence for using any tests (eg, PSA derivatives, PSA kinetics, PSA molecular markers, urinary markers, imaging, or risk calculators) other than PSA for triggering a biopsy referral. While the AUA did not recommend a specific threshold for biopsy referral, they did suggest using a threshold of 10.0 ng/mL for men 70 years and older.

â—The United States Preventive Services Task Force (USPSTF) updated its recommendations in 2012 to recommend that men not be screened for prostate cancer, concluding that there is moderate certainty that the benefits of such screening do not outweigh the harms [213]. The USPSTF did advise that men requesting screening be supported in making an informed decision. The USPSTF clinical practice guideline for screening for prostate cancer, as well as other USPSTF guidelines, can be accessed through their website.

â—The Canadian Task Force on Preventive Health Care makes strong recommendations against screening for prostate cancer with PSA for men younger than 55 or older than 69, and makes a weak recommendation against screening with PSA for men ages 55 to 69 [214].

â—The United Kingdom National Screening Committee does not recommend screening for prostate cancer [215].

â—The Australian Cancer Council states that the evidence does not support population-based screening and recommends a patient-centered approach that individualizes the decision [216].

â—The European Society for Medical Oncology (ESMO) recommends against population based screening and in favor of an individualized approach using shared decision making [217]. ESMO further states that there is inconsistent evidence on screening men younger than 50 and between 70 and 75 years of age, and evidence that the harms of screening outweigh the benefits for men over age 75.

â—The Clinical Guidelines Committee of the American College of Physicians (ACP) produced a "guidance statement" in 2013 based on their rigorous review of guidelines developed by other United States organizations, including the American College of Preventive Medicine, the American Cancer Society, the American Urological Association, and the US Preventive Services Task Force [171]. The ACP guidance statement recommends that clinicians inform men ages 50 to 69 about the limited potential benefits and substantial harms of prostate cancer screening and only screen men who express a clear preference for being screened. The guidance statement also recommends against screening for prostate cancer in average-risk men under the age of 50 and against screening in men over the age of 69 or with a life expectancy less than 10 to 15 years."

-UpToDate, 2016

Emphasis is mine, that's how I base my practice, and I document it that I have 1. had a discussion about benefit and risks 2. reviewed the recommendations based on age and risk factor 3. and in consultation with the patient have elected to [screen via ... ].

YoutubeTheNP · Sep 1, 2016

"The American Cancer Society (ACS) emphasizes the need for involving men in the decision whether to screen for prostate cancer. Men need to have sufficient information regarding the risks and benefits of screening and treatment to make an informed and shared decision; providing them with a decision aid may facilitate the decision-making process [46]. For men who decide to be screened, the ACS recommends PSA testing with or without DRE for average-risk men beginning at 50 years of age. Screening should not be offered to men with a life expectancy less than 10 years. Men whose initial PSA level is greater than or equal to 2.5 ng/mL should undergo annual testing; men with a lower initial level can be tested every two years. The guidelines also recommend beginning screening discussions at age 40 to 45 in patients at high-risk of developing prostate cancer (eg, black men and men with a first-degree relative with prostate cancer diagnosed before age 65). The guideline also recommends keeping the biopsy referral threshold at 4.0 ng/mL. However, for men with PSA levels from 2.5 to 4.0ng/mL, the guideline encourages individualized decision making and risk assessment (http://deb.uthscsa.edu/URORiskCalc/Pages/uroriskcalc.jsp), which can include age, race, family history, digital rectal examination findings, previous biopsy results, and use of five alpha-reductase inhibitors.

â—The American Urological Association (AUA) updated its guideline in 2013 [172]. The AUA recommends against screening men younger than 40, and also does not recommend routine screening for average-risk men ages 40 to 54, men older than 70, or men with a life expectancy of less than 10 to 15 years. Decisions should be individualized for higher-risk men ages 40 to 54, and the AUA noted that some men over age 70 in excellent health might benefit from screening. The AUA strongly recommends shared decision making in deciding on PSA screening in men ages 55 to 69. The guideline panel could find no evidence to support the continued use of DRE as a first-line method of screening. The AUA stated that a screening interval of two years for men who choose screening may be preferred to annual screening and that screening intervals can be individualized based on baseline PSA level. The guideline noted the lack of evidence for using any tests (eg, PSA derivatives, PSA kinetics, PSA molecular markers, urinary markers, imaging, or risk calculators) other than PSA for triggering a biopsy referral. While the AUA did not recommend a specific threshold for biopsy referral, they did suggest using a threshold of 10.0 ng/mL for men 70 years and older.
â—The United States Preventive Services Task Force (USPSTF) updated its recommendations in 2012 to recommend that men not be screened for prostate cancer, concluding that there is moderate certainty that the benefits of such screening do not outweigh the harms [213]. The USPSTF did advise that men requesting screening be supported in making an informed decision. The USPSTF clinical practice guideline for screening for prostate cancer, as well as other USPSTF guidelines, can be accessed through their website.
â—The Canadian Task Force on Preventive Health Care makes strong recommendations against screening for prostate cancer with PSA for men younger than 55 or older than 69, and makes a weak recommendation against screening with PSA for men ages 55 to 69 [214].
â—The United Kingdom National Screening Committee does not recommend screening for prostate cancer [215].
â—The Australian Cancer Council states that the evidence does not support population-based screening and recommends a patient-centered approach that individualizes the decision [216].
â—The European Society for Medical Oncology (ESMO) recommends against population based screening and in favor of an individualized approach using shared decision making [217]. ESMO further states that there is inconsistent evidence on screening men younger than 50 and between 70 and 75 years of age, and evidence that the harms of screening outweigh the benefits for men over age 75.
â—The Clinical Guidelines Committee of the American College of Physicians (ACP) produced a "guidance statement" in 2013 based on their rigorous review of guidelines developed by other United States organizations, including the American College of Preventive Medicine, the American Cancer Society, the American Urological Association, and the US Preventive Services Task Force [171]. The ACP guidance statement recommends that clinicians inform men ages 50 to 69 about the limited potential benefits and substantial harms of prostate cancer screening and only screen men who express a clear preference for being screened. The guidance statement also recommends against screening for prostate cancer in average-risk men under the age of 50 and against screening in men over the age of 69 or with a life expectancy less than 10 to 15 years."
-UpToDate, 2016
Emphasis is mine, that's how I base my practice, and I document it that I have 1. had a discussion about benefit and risks 2. reviewed the recommendations based on age and risk factor 3. and in consultation with the patient have elected to [screen via ... ].

Seems like the majority of these organizations don't encourage it. Thank you for the broad analysis. I was taught to discuss the risk vs benefit of the PSA to the pt as well. I would imagine performing a PSA would come from the request of the pt, is there any provider here that actually offers it?

allnurses Guide · Sep 1, 2016

I offer it after I discuss the recommendations and the potential risks and rewards.

Goldenfox · Sep 1, 2016

Seems like the majority of these organizations don't encourage it.

In some cases, this is because the studies that they cite as evidence for these guidelines are funded by an individual or organization that is somehow connected to a company that markets cancer drugs, or an insurance company or government benefits program that doesn't want to pay for the tests.

I'm sure I read recently that they are recommending decreased frequency of mammograms and PaPs too. I don't always just go by guidelines, it depends on the patient's history, risk factors, and sometimes even ethnicity. One doc who I used to work with said that he does PSAs and prostate exams routinely on African American men because there was plenty of evidence that prostate cancer occurs more frequently in this demographic than any other---even though pretty much none of these studies that they are using to establish the newer guidelines were conducted exclusively with African American test subjects. I remember that there was a whole ethics debate (back when I was doing my doctoral program) over this type of stuff about how some of these studies that we accept as science are biased to fit an agenda and not necessarily so 'scientific' at all.

I read one new study that recommended that PAPs begin at age 25, nothwithstanding that many young women nowadays are sexually active and sometimes also very promiscuous from their early to mid teen years and quite a few of them that I've screened in the past at age 21 were positive for HPV. They are no longer recommending that these exams be done every year as in the past but now every 3 to 5 years, though I know physicians who still do them every year---depending on the patient.

I used to routinely offer both the PSA and DRE to every male patient between 40 and 70 as a part of the annual physical.