Prostate Cancer Roundtable comments on plethora of guidelines on screening


As many readers will be aware, there have been two new sets of guidance about screening for prostate cancer issued in the past few months — the most recent from the American Urological Association just a couple of weeks ago.

In response to the fact that we now have a total of four different sets of guidance (not including the guidance issued by the American Cancer Society) available to the medical community, the members of the Prostate Cancer Roundtable issued the following media release earlier today:

Professionals and Patients Increasingly Confused by Guidance on Screening for Risk of Prostate Cancer

Washington, D.C., May 23, 2013: Representing the interests of the 240,000 American men who are at risk each year for a diagnosis of prostate cancer, and the over 2 million men living today who have been diagnosed with this deadly form of cancer, the membership of the Prostate Cancer Roundtable is increasingly concerned by the utterly confusing guidance being offered – to both the professional healthcare community and to individual consumers – about whether men should or should not be tested (“screened”) for risk of prostate cancer.

At the annual meeting of the American Urological Association (AUA) in San Diego just a few days ago, the AUA issued new guidance about the use of the PSA test to screen men for risk of prostate cancer.1 The newly issued guidance differs radically from prior guidance offered by the AUA itself,2 from guidance offered by the U.S. Preventive Services Task Force in May 2012,3 and from guidance recently issued by the American College of Physicians.4 Each of these three sets of guidance claims to be “evidence based”. The new guidance also differs from that offered by the National Comprehensive Cancer Network.5

“The members of the Prostate Cancer Roundtable fully appreciate that there is great controversy about the use of PSA testing to screen the average, otherwise healthy, Caucasian male for his risk of clinically significant prostate cancer,” said Ana Fadich, VP of Men’s Health Network. “However, the frequent issuance of new guidance documents by a variety of organizations that present differing recommendations based on what is basically the same set of low quality scientific evidence and related opinion leaves men and their doctors confused, upset, and uncertain about what represents good medical practice today.”

The membership of the Prostate Cancer Roundtable also notes that none of the recently issued guidance documents explicitly address the appropriateness of screening of those men at greatest potential risk for clinically significant prostate cancer (largely because there are no good data that address this critical issue). In other words, there is now no clear message at all being given to healthcare professionals about the need for testing in those men who experts in the management of prostate cancer believe to be at significantly higher risk for clinically significant disease than the average, healthy man of Caucasian ethnicity: men with a family history of clinically significant prostate cancer and men of African-American and Afro-Caribbean ethnicity.

“Multiple studies have shown that black males are at greater risk for prostate cancer-specific mortality than white males of comparable age and health,” stated Thomas Farrington of the Prostate Health Education Network. “The lack of explicit guidance about the need for risk testing in this group is potentially a disaster. We have a prostate cancer epidemic among black Americans. This community in particular needs clarity about the role of the PSA test in screening for prostate cancer.”

“Many would argue that there is strong evidence for the value of a baseline PSA test among men in their 40s,” said Merel Nissenberg of the National Alliance of State Prostate Cancer Coalitions. “Such baseline testing is a way to define individual risk and to help men to understand this. However, even the new guidance from the AUA does not offer any definitive guidance on this issue.”

The Prostate Cancer Roundtable is fundamentally concerned that the contradictory guidance coming from different sectors of the medical community reflects two factors: (1) the lack of really good data that offers incontrovertible evidence about screening for prostate cancer – especially among groups of men who may be at particularly high risk levels, and (2) the failure of the differing sectors of the medical community to come together and develop guidance that is issued in the interests of patients and families as opposed to the interests of the professional healthcare community.

We believe that it is time for real leadership from organizations such as the National Institutes of Health and the Institute of Medicine to look at what is needed to develop definitive evidence about the value of screening for risk of prostate cancer – particularly among those groups of men who are known to be at elevated risk levels because of ethnicity and family history. Until such definitive evidence is available, we further believe that every man should be encouraged to have a serious discussion with his primary care physician about whether some forms of testing for risk of prostate cancer may be appropriate for him as an individual (as opposed to the risk of the average, healthy, Caucasian male of 40 to 70 years of age). It is unacceptable that the data on the risks and benefits of prostate cancer screening available today is still not good enough to offer sound advice to any individual patient about risk related to the most common form of cancer now identified in American males (other than basal and squamous cell skin cancers)!

We would conclude by noting that the members of the Prostate Cancer Roundtable are also fully cognizant of the fact that a diagnosis of low-risk prostate cancer does not and should not necessarily imply any immediate need for treatment. The potential problems associated with over-treatment of low-risk prostate cancer need to be addressed as carefully as the problems associated with failure to diagnose clinically significant prostate cancer early so that it can be effectively treated with curative intent.

Source documents:

1. Carter HB, Albertsen PC, Barry MJ, et al. Early detection of prostate cancer: AUA guideline. 2013; downloaded at http://www.auanet.org/common/pdf/education/clinical-guidance/Prostate-Cancer-Detection.pdf on May 16, 2013.

2. Greene KL, Albertsen PC, Babaian RJ, et al. Prostate specific antigen best practice statement: 2009 update. J Urol. 2009; 182: 2232-2241, downloaded at http://download.journals.elsevierhealth.com/pdfs/journals/0022-5347/PIIS0022534709019557.pdf on May 17, 2013.

3. US Preventive Services Task Force. Screening for prostate cancer. 2012; downloaded at http://www.uspreventiveservicestaskforce.org/prostatecancerscreening/prostatefinalrs.htm on May 16, 2013.

4. Qaseem A, Barry MJ, Denberg TD, et al. Screening for prostate cancer: a guidance statement from the clinical guidelines committee of the American College of Physicians. Ann Intern Med. 2013; downloaded at http://annals.org/article.aspx?articleid=1676183 on May 16, 2013.

5. National Comprehensive Cancer Network. Early detection of prostate cancer, version 2.2012. 2012; downloaded at http://www.nccn.org/professionals/physician_gls/pdf/prostate_detection.pdf on May 16, 2013

This statement was supported by the vast majority of the members of the Roundtable (including Prostate Cancer International, the parent organization of The “New” Prostate Cancer InfoLink).

5 Responses

  1. Just my own observations. … The Roundtable is calling for every man to be screened at age 40 and the medical industry sees a problem with that. “Baseline” or otherwise, by testing every 40-year-old man, that is still screening in their eyes. And then the Roundtable plan, I guess, is to depend on the doctor pools to exercise restraint and that is a real Catch 22. One that has led the USPSTF to decide it isn’t a realistic approach either.

    I agree that we need a single standard but then we’ll have to see yet another wordy set of guidelines because, as the Roundtable points out, we don’t have adequate data on screening so we have to arbitrarily set what we think is a best effort using non-scientific evidence. As long as there is a perceived inadequate recognition of the reality of the size of the over-diagnosis and over-treatment in the patient pool, the industry will, in my view, shy further away from the advocacy efforts to call for guidelines, or otherwise, at best, ignore that perception and issue a popular set of guidelines as opposed to a scientific set of guidelines to appease the patient pool.

    Without that new accurate screening test that can eliminate over-treatment and over-diagnosis, any side you take is urinating into the wind of popularity and avoiding science.

  2. Dear Tony:

    I think you are “over-reading” the media release. What the Roundtable is actually saying is that the whole issue of guidelines for screening for risk of prostate cancer is currently based on poor data. Thus, any guidelines that are issued today are (inevitably) poor guidance. The media release goes on to make two specific recommendations:

    (1) That every man should be encouraged to talk to his doctor, starting at about age 40, about what might be appropriate for him as an individual (as opposed to the average, healthy, Caucasian male). This is not a recommendation for or against mass screening at all. It is just good preventive medicine at an individual level. (However, if I came from a family with a significant history of prostate cancer, or if I was an African American, it might well be reasonable to get a baseline PSA level.)

    (2) That organizations such as the Institute of Medicine and the National Institutes of Health need to take a really serious look at what we need to do as a society to be able to develop better guidance about screening for prostate cancer over time.

    I would point out that the controversies over screening are in no way confined to prostate cancer. We have done a poor job as a society in developing and implementing studies that are designed to tease out and differentiate between the need for screening against disorders like breast cancer, prostate cancer, and other cancers among “average” healthy persons and those with well-understood risk characteristics. If we want to have good guidelines, then we need to own up to the fact that the data on which most current guidance is offered is weak, stop issuing poor guidance based on weak information, and implement and execute good studies that can start to resolve the problem.

    As someone who has read with care nearly every relevant document on screening for prostate cancer over the past 20 years, the only thing that I am certain of at the present time is that all the available data is flawed in one way or another (and often in several ways). How can anyone produce good guidance based on such flawed data?

    Again in my personal opinion, the only valid statement that can be issued by anyone at the present time is that, “The available data, which are weak, and of extremely limited value in making recommendations for any type of patient with known risk factors for prostate cancer, are insufficient to justify recommendations for or against mass, population-based screening for risk of prostate cancer with available tests.” This is not a recommendation for or against screening. It is simply a statement of fact.

  3. Mike:

    I think I echoed your first paragraph in my post minus the “over-reading” part.

    Your second paragraph and what it is intended to do in my eyes is to be subliminal or at least so it appears to be. Who’s supposed to be doing the encouraging in that statement? And isn’t “Talk to your doctor” really a “Get a baseline now” message and in the medical community isn’t it really a “They want me to start screening at 40″ message? And, most realistically, whom in the doctors’ pools will not check the PSA box on the blood test and deliver a DRE after saying blah blah (you can use the trombone in the Peanuts cartoons here)? What happens from there will most assuredly remain controversial.

    Still I am in agreement, for whatever that’s worth, with the Roundtable to request further intervention of the NIH and the IoM for a better research plan. Requesting better data on screening is good. A call to end kicking the can down the road while knowing whatever is to come of this request is still down the road. To request the NIH and IoM to fix the issue is, the best I can say, another interesting call for a better scientific approach (mixed with the non-scientific message in calling for baseline screening at 40) that will in the mean time likely still be no different than what we have seen over the last few years — a long wait and an even newer set of guidelines with utter confusion in the doctor’s office from both sides of the stethoscope as we begin our “talk to your doctor” part.

    And I fear, as they say in French “Plus ca change, plus c’est la meme chose!”

    Thank you for the return post. I think in large part we agree.

    Anyway, moving along. I think you just might have hit on a great idea for a next post at the InfoLink. Do you think you can take your 20 years experience with screening and give us a summary post of all the various guidelines you can round up over the last twenty years and a brief description of them. I think it will go a long way in defining what you mean by “plethora”. It will also go a long way in helping the patient pool understand why every time a new set of guidelines hits the streets the message boards light up with confusion and misunderstanding.

  4. Tony:

    Respectfully, I really don’t think that advising men to “Talk to your doctor about what may be the right thing for you” is the same as “Get a baseline at 40″ at all. I think it is a call for us all to stop thinking that guidelines can replace a good conversation. And I think that organizations that issue guidance should be doing it only when there is really good evidence to support it.

    When there isn’t really good evidence, we should just be saying, “We don’t know. We don’t have good enough data.” (I note that this was a tactic that Mr. Bernanke used successfully and with some emphasis when talking to Congress the other day about the economy.)

    With regard to your last comment … You have to be kidding! That’s about a month’s work … and I don’t think it would clarify anything!

    :O)

  5. Healthy debate.

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