The prostate cancer screening controversy redux!

In 1996, the U.S. Preventive Services Task Force (U.S. PSTF) first issued a report stating that the benefits of screening for prostate cancer were far outweighed by the risks. This report was updated in 2002.

As of today,  Tuesday August 5, 2008, the U.S. PSTF has issued another updated version of their guidelines on this subject … and they are still of the opinion that the potential risks of screening far outweigh the potential benefits.

This is a highly controversial subject. As one might expect, the U.S. PSTF’s recommendations are not exactly being met with enthusiasm by the urology community or the prostate cancer advocacy community. The following is a series of quotations from an article in the August 5 issue of the Washington Post:

Those in favor of the guidelines

  • “The benefit of screening at this time is uncertain, and if there is a benefit, it’s likely to be small,” said Ned Calonge (chairman of the 16-member U.S. PSTF). “And on the other side, the risks are large and dramatic.”
  • “We felt with sufficient certainty that your risk of being harmed exceeded your potential benefits starting at age 75,” Calonge said.
  • “There is this idea that more is always better, and if a test is available we should use it,” said Howard A. Brody, a professor of family medicine at the University of Texas Medical Branch at Galveston. “A lot of time we’re doing more harm than good.”
  • “People say, ‘What’s the harm in screening?’ In fact, there are several ways in which screening can actually be harmful,” said Howard L. Parnes of the National Cancer Institute.
  • “If therapy isn’t providing meaningful benefit, then how could screening provide benefit?” Calonge said. “And we know that the therapy produces significant harms.”

Those opposed to the guidelines

  • “I think they’re really missing the boat,” said William J. Catalona, a professor of urology at Northwestern University. “It’s a disservice to patients. A lot of men die from prostate cancer, and there’s just an overwhelming amount of evidence that screening saves lives.”
  • “We have seen a dramatic drop in mortality,” said J. Brantley Thrasher, chairman of the urology department at the University of Kansas and a spokesman for the American Urological Association. “They’re not paying attention to that.” (Dr. Thrasher is also a member of the Scientific Advisory Board of The “New” Prostate Cancer InfoLink.)
  • “Men are living a lot longer and healthier these days. I play golf with 84-year-old guys who beat me all the time,” said E. David Crawford, a professor of surgery and radiation at the University of Colorado at Denver. “You have to individualize treatment. If a 75-year-old man is found to have high-grade prostate cancer, it’s going to kill him, and we can intervene and do something for him.”

Those sitting on the fence

  • “If it turns out that PSA screening and aggressive treatment saves lives, maybe all the harm that it has caused is worth it,” said Otis W. Brawley, chief medical officer at the American Cancer Society. “If PSA screening does not save lives, then it’s clearly not worth it. We just don’t know yet.”

Is there a truth here that we can hang our hats on? Frankly, no, there probably isn’t.

So what does one actually do in the real world? The answer is that one has to make one’s own decisions and then one has to act on them.

The “New” Prostate Cancer InfoLink is of the opinion that there is at least enough data to suggest strongly that the early detection of prostate cancer is beneficial for many younger males (say under the age of 65). Similarly, we consider that there is at least enough data to suggest strongly that the benefits of early detection are probably outweighed by the risks in many men over the age of 75. But each male is an individual and needs to assess his personal risk based on personal criteria and data. Averages are irrelevant to individual decision making.

Here are some things that are highly relevant to individual decisions about undergoing tests for early detection of prostate cancer:

  • Do you understand that having a PSA test and a physical examination do not necessarily imply that a prostate biopsy is an essential next step? Having a PSA test is like having a cholesterol check. On its own it is not diagnostic for prostate cancer.
  • Are you at high risk because of a family history of prostate cancer?
  • Are you at high risk because of a sequential increase in your PSA that appears not to be related to either benign prostatic hyperplasia or a prostate infection?
  • Is your risk of death from prostate cancer low because of comorbidities such as age, heart disease, diabetes, etc.?
  • Do you understand that a positive prostate cancer biopsy does not necessarily mean that you need to undergo aggressive, invasive therapy?
  • If you are 75 years of age or older, have you reviewed the recommendations of the Iowa Prostate Cancer Consensus?

Available data, in our opinion, are still insufficient to absolutely confirm or deny the value of broad-scale screening for prostate cancer. And there is no doubt that there are significant complications to every current form of treatment for localized prostate cancer.

Given this conundrum, we have to say that, in our opinion, each man needs to make his own, very personal decision. He shouldn’t slavishly follow the recommendations of one group over another. Rather, he needs to assess his personal risk and come to judgments based on his view of that risk and a complete appreciation of the potential consequences of treatment. Is this easy? Absolutely not! Is it the right thing to do? Yes, it absolutely is!

The bottom line? Having a PSA test and a physical examination won’t kill you. However, not having such tests might be a self-induced death sentence! And at the end of the day, over-reacting to the results of that PSA test, the associated physical examination, and any resultant biopsy may be as dangerous as not having the tests in the first place!

11 Responses

  1. The task force seems to be saying that if treatment can’t be shown to provide clear benefit, why even start the process by doing testing?

    The task force noted the: Harms of Detection and Early Treatment — “The USPSTF found convincing evidence that treatment for prostate cancer detected by screening causes moderate-to-substantial harms, such as erectile dysfunction, urinary incontinence, bowel dysfunction, and death. These harms are especially important because some men with prostate cancer who are treated would never have developed symptoms related to cancer during their lifetime. There is also adequate evidence that the screening process produces at least small harms, including pain and discomfort associated with prostate biopsy and psychological effects of false-positive test results.”

    If tested and diagnosed, the statistical odds of dying from PCa are only about one in eight; the odds of being harmed by the side effects of aggressive treatment are worse than 50-50. While saving the lives of many with aggressive disease — statistically, current practice hurts more people than it helps. I was surprised that the data on the ACS site don’t show more survival benefit from treatment.

    You make the point not to “over-react” to a PSA test or a biopsy. That’s hard to do when the tests do such a poor job of determining PCa stage and grade — the things that seem to differentiate indolent from aggressive cancers. Until these can be determined more accurately, treatment of the early stage cancer that PSA testing so often detects will continue to be a crap shoot.

  2. Some people would argue that this is the entire issue around the appropriateness of active surveillance as a management mechanism. It removes the vast majority of the harms of treatment.

    The question then is, how do we teach patients not to over-react to data that they commonly do not understand when they are first diagnosed?

  3. It’s that — and it’s more than that.

    Even understanding the facts, in so many situations, patients are left with a conundrum: “a paradoxical, insoluble, or difficult problem; a dilemma.”

    The physicians involved would be the best choice to start the educational process, but from my experience, most docs want to resolve the dilemma and treat, even if it is over-treating and as likely as not to cause side-effects. More treatment choices than the “all or nothing” RP (or ablation, etc.) or watchful waiting options provided for many of the newly diagnosed would also help patients avoid over-reacting.

  4. Of course … so when is the advocacy community going to address the need of the AUA and others to appropriately educate their members? (Please see my comments about this issue on the social network, Steve.)

  5. This “analysis” of the USPSTF position report on prostate cancer screening, Screening for Prostate Cancer: Recommendations and Rationale, is more accurately an analysis of the sound bites the media captured rather than the source document itself. And in that regard, the media were fed the sound bites by the USPSTF Big Dogs, and those sound bites were dramatic and oversimplified.

    The best example is from the USPSTF chair, Ned Calonge, who opined regarding the downside of screening, “And on the other side, the risks are large and dramatic.” In the USPSTF document neither large nor dramatic are used regarding the “harms” that will befall men over 74 years of age. In fact, there is NO reference in the document that fits one of the other Calonge sound bites: “We felt with sufficient certainty that your risk of being harmed exceeded your potential benefits starting at age 75.” The only reference in the document that approaches this for specificity is this under the heading Cost and Cost-effectiveness:

    Current models show that men older than 70 to 75 are unlikely to benefit
    substantially from screening because of their shorter life-expectancy and
    higher false-positive rates.2

    In fact, this latest upgrade of the USPSTF screening recommendations is bland compared to the media show that that was put on by USPSTF. And that’s the problem. Few will read the actual document but rather will be swayed by the media release.

    Education of the medical professionals will only be as effective as the presentation of the educational materials to those professionals because they are “too busy” to read much more than the media treatment of whatever is being presented. And that means that the press release and media show about such educational materials will be more important than the materials themselves.

    The “New” Prostate Cancer InfoLink position piece on the USPSTF should have addressed this aspect. But that would have meant reading the USPSTF document itself.

  6. And the reason we addressed the “sound bites” is for all the reasons that Rick lists. Most people will do no more than hear the sound bites. We did read the actual publication.

  7. The latest pronouncement from the US Preventative Services Task Force is an extension of its long-standing plea to accept ignorance instead of knowledge. Its recently updated statement adds nothing of helpful assistance to the hundreds of thousands of men already diagnosed with prostate cancer, and discourages those who may have the disease but have not yet been diagnosed from submitting to the two, readily available, inexpensive, non-surgical diagnostic tests that might give them a basis for informed inaction or action.

    Ignorance is seldom a reasonable option, and I am outraged that USPSTF has the gall to try to foist the ignorance option off on American men.

  8. Let’s weigh into this issue at the Prostate Cancer Research Institute Annual Conference at Los Angeles next month.

    Phil Olsen

  9. Unfortunately I can’t be at that meeting, but it would certainly be a good place to develop an action plan. The current situation is unacceptable because the guidance for the “man in the street” is insufficiently well defined.

  10. The Task Force has once again done a diservice to men everywhere. As a survivor and activist for alerting men about prostate cancer, I am astonished at their “advice”. As a “prevention” group they have been interpreted by ACS, NCI, and the media to ignore PSA’s . That’s the message that’s getting out. Have any of them been alerted to prostate cancer by a PSA before symptons occur and been treated to live a long life like I and many thousands have? Back to your ivory towers!

  11. I find it appalling that anyone would think it unnecessary to test PSA (or any ensuing tests that become recognized to identify the likelihood of developing prostate cancer) to recognize that cancer is present and developing in order that close attention can be provided that individual no matter what his age. If aggressiveness is noted, treatment should certainly be put to use, or at the very least offered, rather than let the person die “of” rather than “with” prostate cancer. We all are well aware that with appropriate treatment, we can extend the lives of a multitude of patients by many years who would have otherwise met their demise without treatment. It should never be the physician or the government to dictate whether or not to test or to treat. The patient should always be apprised of and offered testing for any medical issues that are known can have an effect on that patient, and only the patient should have the option to accept or refuse such testing or subsequent recommended treatment.

    We all need to continue to encourage prostate cancer awareness, annual PSA testing, and DRE examination so that it becomes common for all men to ask their physician for these tests as part of annual examinations – no matter how much they age. To have developing prostate cancer ignored by the medical community, and we are all aware that our cancer can become extremely aggressive for many, would, in my opinion, be criminal. Here is the “Physician’s Oath” as adopted by the General Assembly of the World Medical Association, Geneva, Switzerland, September 1948 and amended by the 22nd World Medical Assembly, Sydney, Australia, August 1968 (the World Medical Association is an association of national medical associations):

    Physician’s Oath at the time of being admitted as a member of the medical profession:
    I solemnly pledge myself to consecrate my life to the service of humanity;
    I will give to my teachers the respect and gratitude which is their due;
    I will practice my profession with conscience and dignity; the health of my patient will be my first consideration;
    I will maintain by all the means in my power, the honor and the noble traditions of the medical profession; my colleagues will be my brothers;
    I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient;
    I will maintain the utmost respect for human life from the time of conception, even under threat, I will not use my medical knowledge contrary to the laws of humanity;
    I make these promises solemnly, freely and upon my honor.
    We need to hold the Medical Community responsible to adhere to this oath in its entirety. If any physician has abrogated the necessity and responsibilities of this oath, he/she should lose his/her license to practice medicine.

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