There’s a new slide presentation on the Medscape web site that is designed to help primary care physicians keep up to date on the initial diagnosis of prostate cancer and its implications.
If you are going to be a good support group leader or patient educator or advocate, you should be able to get a pretty high score on this slide kit, so it is a useful tool for you to be able to test your own knowledge level! This doesn’t make you a doctor … but it does give you an easy way to make sure you know what you are talking about when you talk to patients about their diagnosis.
Also … This would be a very nice slide presentation to give at a support group meeting to help your members be aware of what primary care physicians should know today about the diagnosis of prostate cancer.
Filed under: Diagnosis | Tagged: Diagnosis, physician, primary care |
THE "NEW" PROSTATE CANCER INFOLINK 
Interestingly, earlier today I forwarded the URL to this slide show to several support lists recommending readers subscribe to Medscape since it is free, and in so doing will open the door to their being able to open and read future Medscape articles.
This was an interesting and helpful slide show, but there were a couple of key concerns that I wish had been presented differently, and I hope that anyone presenting this slide show will call attention to these concerns as they involve critical points involving the value of screening.
One of them involves the US Preventive Services Task Force’s current recommendation which essentially discourages screening, but is not competent. That recommendation against routine screening is mentioned in slide 16. The problem is that the recommendation sounds authoritative and expert, but the reality is that it has been debunked at critical points. Perhaps the most important refutation comes from continuing follow-up from the European Randomized Screening Study for Prostate Cancer (ERSPC) and also from effective discrediting of the Prostate, Lung, Colorectal and Ovarian (PLCO) study as it bears on prostate cancer screening (as contrasted with comparison of two screening programs both of which involved fairly intense levels of screening). The USPSTF recommendation essentially relied on their understanding, which was profoundly flawed, of the ERSPC and PLCO studies — other studies played a minor role, so a sound understanding of these two studies is important in assessing the lack of competence in prostate cancer in the USPSTF.
Also important is the even more robust data supporting active surveillance as both an effective and now fairly popular choice that solves the over-treatment issue. Moreover, as many of us know, none of the voting members of the USPSTF were urologists or oncologists; it was truly a low-expertise panel where prostate cancer was the topic for their review. Slide 16 does present other viewpoints from the ACS and the AUA, but the AUA view of screening does not seem to have taken on board key updates to the ERSPC figures for benefit of screening, especially where actual screening was more rigorous, as contrasted with pseudo screening (randomization to screening group without compliance) and stretched-out screening intervals where the dangerous cancers we really need to detect can slip through and make screening look bad when an overlong screening interval is the real culprit.
The other concern involved other aspects in the table for slide 16. The second block under the risk side of the table says that “DRE and PSA screening has not lowered annual death rates from prostate cancer.” That statement suggests to an uninformed lay audience that screening does not help, and the statement is not in line with the trend of follow-up evidence from the ERSPC, which now shows a distinct survival advantage for screening. The statement also focuses attention on death while ignoring other benefits, such as reduction of pain and suffering when wise treatment is performed.
The third block on the risk side of slide 16 is about the harms resulting from screening or treatment. Most unfortunately, it neglects to mention that harms of over-treatment can be avoided by wise use of active surveillance. Additionally, as we know, there is growing use of multi-parametric MRI and other pre-biopsy information to home in on the situations where biopsies are of greater value.
The fourth block on the risk side of slide 16 says that “True positive screening results do not definitively indicate benign versus malignant conditions.” That statement will be somewhat unclear to an uninformed lay audience. Taken one way, it suggests the old “coin-flip” fallacy, suggesting that screening results are of no value, when in fact they are an important part of a work-up for problems with the prostate, including cancer. The text also fails to mention that PSA is a multi-purpose sentry that also signals possible presence of BPH and infection as well as possible presence of cancer.
While much of this slide presentation is aimed at primary care doctors and would not be of great or “take home” interest to a general lay audience, slide 16 is key as it discusses pros and cons of screening. This slide deserves extra time to prevent serious false impressions.
Dear Jim:
I am sorry but I simply cannot agree with your over-analysis of slide 16 of this presentation. The basic point being made by the authors is that widespread screening is “highly controversial for asymptomatic men older than 50 years.” This is a simple fact, and to describe the members of the USPSTF as “low-expertise” is gratuitously insulting. Furthermore, this slide presentation was never intended for lay presentation by the authors.
Should it be used in a lay presentation, I would argue that yours is an extremely over-positive view of screening. That does not make it “wrong” … but the only fair way to look at (or present) this slide is to give both sides of the argument, and in contrast to your perspective I would point out that there is a now an enormous amount of data supporting the authors’ perspective. I would also note that despite the more recent findings of the ERSPC trial, this was not a single-methodology trial but rather a meta-analysis of a series of very different screening studies whose results need to be interpreted with a great deal of caution. Even the senior authors of the ERSPC study still state that its results do not justify widespread PSA screening.
The slide that bothered me the most was #12: “A 63-year-old man presents to his internist with a screening PSA level of 14.2 ng/mL. On DRE, the clinician notices a distinctly irregular prostatic border. In view of the potential for a prostatic malignancy, which of the following is the most appropriate next step for diagnostic purposes?”
There was no option presented for “3T multi-parametric MRI” and, possibly, a subsequent fusion-guided biopsy.
On the next slide (#13), the “correct” answer is: “On the basis of the clinical findings, the best next diagnostic step is to obtain a TRUS-guided prostate biopsy.”
Here we go again: Get thee to a “blind” biopsy forthwith.
Dear Walt:
In most of the country (not to mention most of the world) access to a 3-T multiparametric MRI isn’t even feasible yet. A biopsy carried out after an mpMRI is still a TRUS-guided biopsy: it’s a TRUS-guided biopsy with the additional benefit of the MRI information. Thus, while I would agree with you that it would have been nice if the authors had suggested either a TRUS-guided or (better still) an MRI/TRUS fusion-guided biopsy, the answer is still correct in that this patient needs at least TRUS-guided biopsy (because of the positive DRE).