Keeping up to date with the screening controversy

Many readers may be interested in two articles on the “screening controversy” in the May issue of Oncology News International.

In the first article, several well known specialists (Crawford, Bach, Raghavan, Moul) give their interpretation of the current situation and how they are talking to their patients today.

In the second article, a survivor gives his “take” on the situation.

We note a specific quote from page 2 of the first article: “the American Urological Association supports PSA-based screening in men ages 40 and up.” We have already warned that this is how the new AUA guidance document would be interpreted, and again point out that this is not an accurate representation of that guidance, which recommends a baseline PSA at age 40 for well-informed men who believe they are at risk, but also clearly states that the use of PSA testing should be individualized.

4 Responses

  1. Mike:

    When I read the AUA guidelines it appeared to me that they saw PSA/DRE as something that has the potential to be appropriate BUT that the rush to biopsy may be more problematic. Maybe the discussion that benefits men should be more about when is it appropriate to do a biopsy rather than when and if to do a PSA/DRE?

    It may be years before we have an alternative marker to PSA but if the medical community can use the information we have now to make differential decisions then wouldn’t men be better served? At least that way, in the practical world of men’s health, decisions could be made on knowns rather than unknowns?

    The issue is how do we balance “do no harm” to men with aggressive cancer and “do not harm” men with slow-growing cancers. I wonder how many men who are under 55 and diagnosed with aggressive or advanced disease have none of the known risk factors?

  2. Kathy:

    Congratulations. The issue of balance is exactly the point I have been trying to make ever since these guidelines came out!

    The problem is that we have no idea what percentage of men with no known risk factors may actually have aggressive disease at the time of diagnosis (and we commonly will still not know that even at the time of diagnosis, based on the currently available data). Furthermore, you need to remember that the known risk factors are not necessarily risk factors for aggressive disease. If your father and your grandfather both had prostate cancer at some point and died of old age at 90, then you aren’t necessarily at risk for clinically significant or aggressive disease — although you are certainly at increased risk for a positive biopsy!

    The rush to biopsy is indeed a major part of the problem, not the existence and appropriate use of PSA and DRE testing. My concern all along has not been with the testing — it has been with how people think about the testing and what it means. This is where the AUA’s proviso in its guidance about the “well-informed” man is so important. Most men, told that they have a PSA of 2.5 or higher, have now “learned” that they should immediately have a biopsy, and if that biopsy is positive they want immediate (and often potentially inappropriate) treatment. Re-teaching all those doctors and patients about a better approach to risk management based on baseline PSA levels and active surveillance protocols is going to be tough — especially if large numbers of members of the urology community don’t actually follow the AUA guidance, which they probably won’t.

  3. It’s a bit late here but I would like to comment further tomorrow night if that’s ok?

    I would though like to highlight this from the second article:

    “Thomas Stamey, MD, considered to be the father of PSA testing, said that it is not the results of a single test but the trend of those results that is critical. The secret to the successful treatment of any cancer is early diagnosis. PSA testing is merely a tool, and when paired with a digital rectal exam, it can support a wait-and-watch approach so that biopsies or other tests are ordered only when warranted.”

    From my research this has always been the case but whether it’s down to the financing of new invasive equipment the basics have been somewhat ignored especially in the USA?

    I think the new AUA guidelines are near spot on and not just for people who think they are at a higher risk of PC but for informed men who want to know their PSA baseline for future reference,whether they get tested the next year or say five years later!

  4. My good friend Tom used to say a lot of smart things — even though he wasn’t right all of the time! He still managed to teach me most of what I initially learned about the diagnosis and management of early stage disease (as I organized courses for urologists he used to teach at).

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