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IADT3since2000 · 05-22-2012, 07:22 AM

Yesterday the US Preventative Services Task Force (USPSTF) issued the final version of its recommendation against routine screening for prostate cancer, believing that screening does little good and but substantial harm, mainly due to side effects of unnecessry treatment.

Here is what a reporter from the Washington Post highlighted in his article about it: "... the task force concluded such testing will help save the life of just one in 1,000 men...." That point is based on analysis of two studies that played a dominant role in USPSTF thinking, the PLCO trial (Prostate, Lung, Colorectal and Ovarian) and the ERSPC trial (European Randomized Screening for Prostate Cancer). Both those trials have been previously discussed on this Board, from the time of initial publication in 2009, and both have been updated based on more years of following patients in the trials.

However, the essential, critical flaw remains the same for both, even after the additional follow-up: inadequate follow-up time to allow visibility of the extent of benefit, specifically deaths avoided. The Task Force clearly recognizes that typically prostate cancer patients will survive from diagnosis for more than a decade, but it fails to connect the dots and see that this means follow-up in trials, in order to gauge the extent of survival benefit, must be years more than a decade! Instead, the Task Force relies on follow-up from time of enrollment in the trials rather than from time of diagnosis. The consequence is that the follow-up periods in the PLCO and ERSPC trials on which the Task Force is resting its case are simply far too short to be meaninful! Therefore, concluding that testing will save the life of just one in a thousand men is a premature and unwarranted conclusion.

I am not completely surprised the Task Force failed to come to grips with this mistake and many others in its draft report, but I am disappointed. Its draft report was so misleading that many in the prostate cancer community had doubts whether the Task Force was competent to understand the disease and come to correct conclusions. However, the Task Force requested and received public comment, in fact receiving a mountain of critical responses, and I had some hope that the comments would enable the Task Force to alter its recommendation. However, modern medicine is a highly specialized enterprise, and no voting member of the Task Force treats prostate cancer in their medical practice. As I read the final recommendation, I again saw the signs that were in the draft version that the Task Force has a fundamentally limited understanding of prostate cancer. I'm reminded of the old saying that "A little knowledge is a dangerous thing."

The Task Force is essentially concerned with the problem of overtreatment and resulting harms. The problem of overtreatment of prostate cancer is real, as is widely acknowledged in the medical community that is familiar with prostate cancer. However, the wise solution, as I see it, is not to cease screening, rather it is to employ the now proven strategy of active surveillance for men with low-risk case characteristics. That solution has been strongly endorsed by highly influential professional medical organizations like the American Urological Association. While the Task Force understands the mechanics of what active surveillance involves, the Task Force does not address the key role of active surveillance in solving the overtreatment problem. In other words, the solution the Task Force should have found is to use our power to observe and think rather than emulate the ostrich and stick our heads in the sand.

I have posted general points here, but I can provide detailed backup information.

One way or another, the Task Force recommendation needs to be withdrawn. The Task Force missed a great opportunity to join in the endorsement of active surveillance.

Jim

Tall Allen · 05-24-2012, 12:35 AM

Except for high risk groups like African-Americans and first-degree relatives of those who've had PC, I pretty much agree with the USPSTF that PSA is a widely abused test, and that PC is vastly overtreated. They infer from that that PSA screening ought to be eliminated, while I see those as fixable problems. In particular, I question two of the assumptions that led to the USPSTF recommendation:

Slippery Slope
Their recommendation assumes that an elevated PSA reading will lead to biopsy, which if positive, will lead to radical therapy. This is, sadly, the way it often works. We must acknowledge the shortcomings of the PSA test and take steps to overcome them. Because PSA lacks specificity, it behooves us to eliminate the non-cancerous sources of PSA. There are several available methods for doing so:

1. Reduce the confounding effect of bacterial prostatitis with a course of Cipro or other suitable antibiotic. If PSA is normal, do nothing. If still elevated and below 10 =>

2. Reduce the confounding effect of BPH with a six month course of finasteride. If PSA is then normal, continue with finasteride. If elevated or rising =>

3. Wait 3-6 months and retest. If PSA is stable, do nothing. If PSA doubling time is less than 3 years =>

4. Use Free PSA, PCA3, (and -2ProPSA and TMPRSS2:ERG when they become widely available), DRE and imaging tests together with available nomograms to determine if biopsy is warranted. Discuss with patient the probability of indolent disease, the risks and opportunities of active surveillance vs radical therapy. =>

5. Only then should a biopsy be performed.

Following a diagnostic flow chart like this will vastly eliminate overtreatment due to PSA testing. Notice in #3 that I am recommending something the Task Force did not address: that PSA testing should never be a single screening event, but should be tracked over time. Part of the solution is to do more of it, rather than eliminate it. The above measures will improve the diagnostic accuracy of the test. Future tests will distinguish indolent from progressive disease.

The Cure is Worse than the Disease
This has historically often been the case. However, the Task Force did not consider that the morbidities of some of the therapies that have emerged in the last ten years are quite a bit less than those associated with surgery or conventional EBRT. All of the following therapies as offered in state-of-the-art institutions, are curative in most cases and do not carry the same urinary, rectal and sexual side effects associated with the more prevalent therapies:
1. HDR Brachytherapy
2. LDR Brachytherapy
3. Hypofractionated SBRT
4. Pencil beam proton therapy
5. Focal therapies (in well-chosen cases)

Most institutions now have Active Surveillance protocols in which very low risk and low risk patients are closely monitored for disease progression, and elect treatment only when necessary.

In short, there is no necessary connection between PSA screening and the morbidities associated with treatment. PSA screening is a necessary part, but only a part, of a comprehensive diagnostic and treatment plan.

- Allen

starr15 · 05-24-2012, 11:16 AM

There is no correct answer for most men with our current state of knowledge. Only in hindsight will the correct course of action be known for a man, and maybe not even then.
A man 55 or older with a PSA between 1.1 and 2 has about a 17% change of biopsy detectable prostate cancer. Of those cancers, about 12% will be Gleason 7 or higher.

"In light of these new studies, what should a man do? Says Dr. Carter: "I like what Dr. Michael J. Barry, M.D., medical director of the John D. Stoeckle Center for Primary Care, said in his NEJM editorial about the studies. He wrote, "The implications of the trade-offs reflected in these data, like beauty, will be in the eye of the beholder. Some well-informed clinicians and patients will still see these trade-offs as favorable; others will see them as unfavorable."

Donate to prostate cancer research!

mudrunner · 05-24-2012, 01:16 PM

While doing my AUS pre-op visit two days ago, my uro doc brought this subject up. I thought her head might explode as she was so agitated over "the stupidity" of this decision. Rhetorically, she asked if I'd ever seen someone die from bone mets and how unpleasant that was. No...but I was holding my brothers hand when he passed from stomach cancer...and I didn't care to experience anything more than that.

As a 12 year PC survivor I've often been asked about this PSA test/no test issue. As far as I'm concerned - statistics be damned - if it's one in a thousand and you are the ONE, the numbers don't mean diddly. Thorough and careful evaluation and testing can reduce the errors we all know take place. My initial tests didn't look terrible but did indicate a more in-depth evaluation was needed and doing that saved my cookies for sure. My RRP gave me twelve years to survive multiple skin cancers and allows me to keep fending off stage 2 grade 2 follicular non-Hodgkins lymphoma. The RRP induced lymphedema in my left leg and 24/7 leaking have been problematic (this to be fixed next week...I hope) but it sure beats the alternative which was only averted by the PSA TEST! It never ceases to amaze me how incredibly stupid so many supposedly well educated "experts" can be.

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