A critical session at the GU cancer meeting this morning was designed to address the pros and cons of screening patients for prostate cancer.
It would be fair to say that, even in light of the new guidelines issued by the American Cancer Society on Wednesday, there is probably greater consensus between the different organizations today than ever before, as Dr. Peter Carroll of the University of California at San Francisco pointed out in his initial presentation. But, as Americas Prostate Cancer Organizations have noted, there is still great confusion among the general public, and men at potential risk don’t know that they should be doing.
In his “pro” screening presentation, Carroll emphasized that, as far as he was aware, no organization today was recommending mass, population-based screening and no one was recommending that no individual get tested for early detection. The consensus is around the need for appropriate testing of specific types of individual based on their potential risk for prostate cancer. However, the devil is in the details and how we ensure that patients and their physicians work well together to make good decisions that have the following outcomes:
- Early detection of clinically significant prostate cancer that may lead to metastatic disease and/or death
- Avoidance of detection of indolent prostate cancer who are at absolutely minimal risk for clinicaly significant disease
- Changing the current close association between early detection and the immediate need for treatment so as to minimize over-treatment and minimize the impact of over-treatment on patients’ quality of life
In his “con” presentation, Dr. Peter Boyle of the International Presentation Research Institute gave a very clear explanation of why mass, population-based screening was not a viable strategy for the early detection of prostate cancer, as seen from a public health perspective. However, as we have pointed out above, this may no longer be the issue that is under discussion. What we are trying to address today is how we use the currently available tests more effectively in order to diagnose and treat the patients who really need that diagnosis and treatment while avoiding unnecessary diagnosis and unnecessary treatment in men with very low-risk and low-risk disease.
As a follow-up to these two studies, Dr. Eric Klein of the Cleveland Clinic made a very strong argument, yet again, for the use of 5α-reductase inhibition (with finasteride or dutasteride) to prevent prostate cancer in a defined subset of men — probably those who have a PSA somewhere between 1.3 and 2.0 ng/ml at a relatively early age. Now there are men who have significant side effects to 5α-reductase inhibitors, and clearly those men will need to decide whether they want to use or stay on these drugs, but these side effects do not impact the majority of patients.
Finally, Dr. Otis Brawley of the American Cancer Society further addressed the entire of issue of distinguishing between the need to screen populations for prostate cancer (which he passionately rejected) and the need to identify and cure clinically significant prostate cancer in the men at high risk for such disease (which he greatly favored).
So perhaps it really is time to get everyone onto exactly the same page — because we all do seem to be very close together (at last). Of course we still need a better test than the PSA and the DRE!
Filed under: Diagnosis, Management, Prevention, Risk | Tagged: early detection, Prevention, screening
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Here is a link to an article by Jacqueline Strax (based on an interview with Dr. Otis Brawley) entitled “Prostate Cancer Planner Never Takes PSA Test.”
Here is telling quote from another interview with the biased Dr. Brawley, when he was at Emory University Medical Center. What he says in formal presentations seems to be somewhat different than his less formally prepared remarks. I think the real Otis Brawley is revealed in unprepared interviews. That is my OPINION. – John@newPCa.org (aka) az4peaks
Dr. Brawley: – And by the way, we at Emory have figured out that if we screen 1,000 men at the North Lake Mall this coming Saturday, we could bill Medicare and insurance companies for $4.9 million in health care costs [for biopsies, tests, prostatectomies, etc]. But the real money comes later–from the medical care the wife will get in the next three years because Emory cares about her man, and from the money we get when he comes to Emory’s emergency room when he gets chest pain because we screened him three years ago.”
az4p NOTE: This is pure scare tactics to support his anti-PSA view, and has no supportable scientifically-based evidence.
Interviewer: You’re saying that screening creates long-term customers. So, did Emory Healthcare decide to go ahead with the free PSA screening on Saturday?
Dr. Brawley: “No, we don’t screen any more at Emory, once I became head of Cancer Control. It bothered me, though, that my P.R. and money people could tell me how much money we would make off screening, but nobody could tell me if we could save one life. As a matter of fact, we could have estimated how many men we would render impotent … but we didn’t. It’s a huge ethical issue.”
az4p NOTE: He was successful in stopping free screening by Emory and has now been successful in discouraging PSA testing support by the ACS. I’m not talking about mass screening, I’m talking about screening within the confines of the medical relationship between a Doctor and Patient. — John@newPCa.org
Here is what I sent to you before, with my stance on PSA screening:
Comment by John E. Holliday, FACMPE re: PSA Screening Controversy
Critics of PSA screening for prostate cancer (PCa) generally base that opposition on the view that “over-treatment” of PCa is substantial and in some minds, is rampant. An academic discussion as to the advantages or disadvantages of mass screening may have a legitimate place in the public forum, but the pragmatic realities of PCa in the lives of American men, demand that those of us who constitute the 2 million men presently living with the disease, speak for those who can no longer speak for themselves. Those who have died from what is so often characterized as a largely “indolent” disease.
When opining “over-treatment,” It is easy to talk broad statistics and draw conclusions based on collective numbers, but that does not address the crux of the diagnostic dilemma for the individual patient. The unanswered question is WHICH individual patient’s malignancy is going to remain indolent and WHICH individual patient’s Cancer is going to advance?
Is there some over-treatment in individual cases, undoubtedly, just as there is under-treatment in some individual cases as attested to by the statistics. But, what is the alternative? Should we do away with the most successful warning marker in the history of cancer? Should we wait until there are clinical symptoms and return to the dismal statistical results of the pre-PSA past?
Let’s examine the facts!
The FACT is that there is NO reliable way to determine, with any certainty, which Prostate Cancers (PCa) will remain indolent and which are to progress to life threatening status. If such technology and expertise were available, PCa would not subject newly diagnosed patients to the treatment quandary in which they find themselves.
There should be little doubt to any logical mind, that the introduction of the PSA blood test and the substantial increase in aggressive treatment due to the widely acknowledged transition in presenting diagnosis, from predominantly “ADVANCED” cases in the pre-PSA era to equally statistically predominate “EARLY STAGE” disease today has saved many lives from PCa death.
In the PRE-PSA era (the very late 1980′s backward) roughly 3 of every 4 men diagnosed, was found to have advanced disease and 65% of that group, already exhibited metastases. Today, enjoying the benefit of the PSA era, ((essentially the 1990′s forward), which according to the NCI division of the NIH, has advanced PCa detection by 7 to 9 years, the exact statistical reversal now exists, with over 3 of every 4 men presently being diagnosed, presenting with EARLY STAGE disease.
During roughly this same time period (the PSA era), the number of deaths directly attributable to PCa has DECLINED by approximately 40%. This is true, in spite of the steady expansion in the size of the age group composing the risk pool for those most likely to acquire the disease. These are plain, undeniable, raw figures, not subject to the risk of manipulation that can sometimes taint “adjusted” data.
What then is the most likely reason for this rather dramatic decline in PCa mortality? Has there been any dramatic new discovery in treatment that has substantially extended the expected individual or collective survival rate? NO! Therefore, the logical explanation, and in my opinion, one reasonably supported by the limited statistical data available, is that the advance in diagnosing PCa at an early, curable stage and the resulting increase in the application of aggressive treatment, has been the most likely impetus, for the most substantial mortality decline of any Cancer, in the last 20 years.
Those who WRITE about this disease, rather than personally live it, are great at stating the obvious. “We need to have better, Cancer specific diagnostic tests.” Of course we do, but we don’t have them now, and to discourage the use of what we do have available, just because it is not perfect, is to me grossly irresponsible. If, as some suggest, we only tested men with a family history of PCa, we would miss the majority of PCa tumors that are found to exist today. I don’t favor mass screening, mainly because we don’t yet know what to do with the results, but I heartily endorse the screening of individual patients who are interested in their health and who are seeing Physicians.
Realistically, we recognize that our appointment time with a physician is usually limited. In my opinion, instead of urging that such time be spent explaining the ins and outs of the PSA debate, BEFORE ordering a PSA test, it would be far more productive to use that equivalent time, in educating patients about the true significance of their previously ordered, PSA results.
It is not enough to keep stating where we want to go, we need to create a map and outline the specific route(s) to get there. It is very easy to state the problems, to attack the weaknesses in the present system, to bandy about the obvious, but it is much more difficult to provide true solutions. Here is one suggestion!
Prostate Cancer prompts much the same, or very similar, symptoms as Benign Prostate Hyperplasia (BPH) which is the natural growth of the Prostate, experienced by most men from their 40’s forward. By having a baseline PSA at 40 y/o, while the potential effect of significant BPH is low, you have the best chance of establishing a “normal” PSA, for YOU. Such information, coupled with the results of a Digital Rectal Exam, could help immensely in the decision making process following any “suspicious” results at a later date, more common with advancing age.
How does my PSA compare to other men in my age group? Dr. Catalona at Northwestern did a study that detected the following median PSA levels (50% above/50% below), for the following age groups:
Men in their 40’s = 0.7 ng/ml
Men in their 50’s = 0.9
Men in their 60’s = 1.3
Men in their 70’s = 1.7
These represent typical levels of PSA found in these groups and are NOT absolutes, but they do provide some ROUGH guidelines as to what could be considered as somewhat “normal” for these age groups. The basis for the making of informed decisions can be enhanced, by knowing such data, if it is used in proper perspective.
So should you, or should you not, get a screening PSA blood test?
It remains an individual decision and every indication is that it will continue to be so in the foreseeable future. Until something is proven to perform better, at as reasonable a cost, I would suggest that a PSA blood test coupled with digital Rectal exam, is the best means of monitoring your Prostate health.
Once you have the results explained, THEN and only then, can you decide its true significance and what action, IF ANY, you wish to take for follow-up. Without this combination you know NOTHING and to NOT have this recommended Prostate Examination, leaves you without the information necessary, to make intelligent, informed decisions.
But it remains, as it should, YOUR decision and your decision only! – John@newPCa.org. (aka) az4peaks
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As long as there are activists (and leading doctors) who believe that PSA screening is for the benefit of all men, this issue will never be resolved.
Here’s a leader in the prostate cancer world, Dr Walsh:
“If you are the kind of person who doesn’t wear a seat belt nor goes regularly to the dentist or your family doctor for a check-up and are not worried about dying from prostate cancer, do not undergo PSA testing. On the other hand if you are a healthy man age 55-69 who does not want to die from prostate cancer, the European trial provides conclusive evidence that PSA testing can save your life.”
Dr Catalona has a similar view, so it is said.
John,
That is the best, most succinct argument I have seen to date on this derisive issue. I whole heartily agree with your reasoning and conclusions.
Thank you,
Bill
I could add no better analysis than that provided by John. Well done. The negative reaction to the ACS release (actually, more so of Dr. Otis Brawley) in the prostate cancer survivor community is mounting. I would have been dead years ago had I not been provided the accessiblity to free screening.
I too am amazed and appalled at the new ACS recommendations. They are probably correct in determining that some men who are diagnosed with prostate cancer are getting prematurely treated or over-treated for it, but that isn’t the fault of their having been diagnosed, it is the fault of what happens AFTER they are diagnosed. Early detection is key to prostate cancer survival. Anyone who suggests otherwise is someone who never expects to experience the disease themselves!
What is needed is not to delay or forgo detection, it is more conversation and education about “Okay, what do we do about it?” after it has been detected. THAT is what ACS SHOULD have recommended.
One can only hope ACS corrects itself on this matter before too many thousands of men are condemned to the misery of advanced prostate cancer by the recommendation they have made.