Yesterday evening, the American Urological Association (AUA) issued a new, formal statement on the role of PSA testing in assessment of risk for prostate cancer: “Information Sheet: Prostate-specific antigen (PSA) testing for the early detection of prostate cancer.”
Despite the vehement statements from some in the urology community in response to the recent recommendation issued by the U.S. Preventive Services Task Force (USPSTF) about widespread prostate cancer screening with the PSA test, this new document from the AUA is interesting because, for the first time, the AUA appears to clearly and explicitly acknowledge the relevance of a patient’s awareness that the potential consequences of PSA testing do carry real risks for individual patients:
The AUA believes that the decision to test for prostate cancer requires an in-depth discussion of the pros and cons of testing where a patient and his healthcare provider can have an honest and frank interchange and any questions a patient may have can be answered clearly. If, after this discussion, a patient wishes to be tested, they should be tested. In order to be effective and to minimize the risks of over-diagnosis and over-treatment, prostate cancer testing must be individualized based on a man’s risk factors.
Indeed, the word “screening” does not appear in this new statement from the AUA at all, and The “New” Prostate Cancer InfoLink congratulates the AUA for this step. The real controversy about use of the PSA tests in assessment of risk for prostate cancer has never been about its value in signaling the possibility of that risk. It has been about the excessive, annual use of the PSA test in healthy men with no known risk factors for prostate cancer, which has led to an excessively high level of diagnosis and over-treatment of low- and very low-risk forms of prostate cancer, particularly in older men who are found to have pathologic evidence of cancer and who (because of our ingrained, societal fears about any diagnosis of cancer) then insist of treatment from which they are most unlikely to gain any benefit and which commonly is associated with a well understood series of potentially significant harms.
The AUA also, correctly, points out in this new statement the importance of separating the idea of risk assessment (through the appropriate use of PSA tests and digital rectal exams) from the subsequent need for actual diagnosis and treatment, implying the importance of careful, sequential discussions between doctors and patients about the risks and harms associated with prostate biopsy and the importance of full explanation of the relative merits of treatment as compared to some form of monitoring (in carefully characterized individuals) based on the clinical characteristics and the personal desires of the individual patient and his family.
Of course we shouldn’t be surprised that the AUA continues to “blame” the USPSTF for issuing a recommendation with which most urologists disagree, but The “New” Prostate Cancer InfoLink cannot help noticing that there is an interesting correlation between the above-mentioned quotation from the AUA’s statement, and the following quotation from the USPSTF in their formal discussion of the clinical implications of their recommendation:
Although the USPSTF discourages the use of screening tests for which the benefits do not outweigh the harms in the target population, it recognizes the common use of PSA screening in practice today and understands that some men will continue to request screening and some physicians will continue to offer it. The decision to initiate or continue PSA screening should reflect an explicit understanding of the possible benefits and harms and respect the patients’ preferences. Physicians should not offer or order PSA screening unless they are prepared to engage in shared decision making that enables an informed choice by the patients. Similarly, patients requesting PSA screening should be provided with the opportunity to make informed choices to be screened that reflect their values about specific benefits and harms.
It would, perhaps, have been helpful if the USPSTF had been careful to distinguish, in this paragraph, between the use of the term “screening” (to mean the regular, mass, population-based testing of all men within a defined age range) and the “testing” of individuals who either are known to be at risk or wish to make an assessment of their personal risk for prostate cancer at a point in time.
The careful reader and analyst might, with real benefit, start to appreciate that the AUA and the USPSTF are not nearly as far apart as some may wish to paint them.
The “New” Prostate Cancer InfoLink suggests that it is time for the prostate cancer patient community, like the AUA, to drop the use of the term “screening” and to focus on:
- The importance of the right of the individual patient to be tested for risk of prostate cancer if that is his wish, and
- The need for all men to be appropriately educated over time on the risks associated with the possibility of a diagnosis of prostate cancer (as opposed to the need for annual mass screening programs).
In the e-mail to its members distributing the link to the new formal statement, the AUA has also said that
Early next week, we will also be providing … a “toolkit” (including additional information, patient materials and slides) to assist you in educating your patients, the public and your local medical community about why the early detection of prostate cancer is critical. These materials will also be available online at www.AUAnet.org/USPSTF.
The “New” Prostate Cancer InfoLink will be watching for this additional information.
Filed under: Diagnosis, Management, Risk |
THE "NEW" PROSTATE CANCER INFOLINK 
I hadn’t even made it through the AUA quote (third paragraph) before it was apparent that they had lifted almost verbatim from the USPSTF statement, which clearly many, many, many “advocates”, physicians, and even urologists never bothered to read in its entirety.
The prostate cancer community’s selective outrage at the USPSTF while adopting their recommendation reminds of the old saw: “There are two kinds of statistics, the kind you look up and the kind you make up.”
Mike unfortunately the use of the word is not part of the mission of USPSTF. They say on their website:
“USPSTF recommendations have formed the basis of the clinical standards of many professional societies, health organizations, and medical quality review groups. Previous editions of the Guide to Clinical Preventive Services have been used widely in undergraduate and post-graduate medical and nursing education as a key reference for teaching preventive care.
“The work of the USPSTF has helped establish the importance of including prevention in primary health care, ensuring insurance coverage for effective preventive services, and holding providers and health care systems accountable for delivering effective care.
“USPSTF recommendations highlight the opportunities for improving delivery of effective services and have helped others in narrowing gaps in the provision of preventive care in different populations.”
We have yet to see what the impact on the groups above. If their objective was early detection in appropriate populations then it seems to me they would have rate it as a “C” which would recommend discussions in the primary doctors’ offices. Seems almost as if they want to cut off discussion.
Dear Kathy:
I am sorry. I am not at all sure what point you are trying to make. Let me be very clear for the 400th time that the USPSTF is only “not recommending” frequent, mass, population-based, screening of healthy men for prostate cancer.
The issue of early detection of prostate cancer is not a matter on which USPSTF has ever commented. All they have ever said is that there are no good data to justify frequent, mass, population-based screening because there is minimal impact on mortality among the entire population. It appears very clear to me that the AUA has just concurred with that recommendation (even though they may not wish to admit it).
The fact that appropriate PSA testing among a definable set of males (inclusive of those who may have an elevated baseline PSA test in their 40s) may have an effect on mortality has never been denied by the USPSTF. However, it has never been formally demonstrated by the urology community either.
The mission of the USPSTF is “to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, or preventive medications.” Counseling of individuals known to be at risk for a specific disorder falls within those criteria, but that does not mean the USPSTF would recommend mass, population-based screening by giving it a “C” recommendation.
You appear to be missing the distinctions here … but then so are many others.
Here’s what I hear in all of these words:
(1) At present, the medical community cannot determine which prostate cancers are aggressive and which are not
(2) Treating non-aggressive prostate cancer cases causes more harm than good. (Are there accurate statistics, other than “many?”)
(3) Doctors are free to advise men on the proper course of action as they deem appropriate
(4) PSA testing is flawed because it isn’t 100% accurate
(5) Therefore, since the medical industry can’t distinguish which prostate cancers are aggressive, routine screening for prostate cancer should be stopped.
I do not agree.
I would think that the USPSTF might take a leading role in creating programs that educate men about the risk and the lifestyle changes they can make to reduce their risk developing prostate cancer – prevention of the disease.
Another good USPSTF initiative might be to focus on the development of new and better diagnostic tests, which would reduce over treatment and adverse side effects.
A third USPSTF program might be the development, funding, and implementation of a nation-wide program that educates men about prostate cancer, the dangers of over treatment – using real statistics, not words such as “many,” “often,” or “most,” and which treatment options are most effective.
The Prostate Cancer Awareness Project Manifesto: “Every man — and his family — has a right to know if he has prostate cancer while that prostate cancer is in a treatable phase.”
Our collective challenge is to create the tests and the system to provide this information, while minimizing unnecessary treatment.
I invite your response.
Mike we will have to agree to disagree. They say on their website:
The mission of the USPSTF is three-fold:
To evaluate the benefits and harms of specific services for patients based on their age, sex, and risk factors for disease.
To make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations.
To identify a research agenda for clinical preventive care.
To identify a research agenda for clinical preventive care.
Their target audience is primary care MDs. If they used a C grade they still would not be recommending routine screening. This is what they did for mammography for women under 40. If doctors look at the grade alone the reality is that they will recommend against having a PSA. This is not about mass screening. A grade C still would not endorse mass screening.The grade D seems to be saying the harms far out way any benefit.
As one man said to me yesterday, I will just continue eating tomatoes and drinking red wine. Don’t need to see a doctor unless there are symptoms.
Dear Robert:
I am in complete agreement with your manifesto, but the programs that you are suggesting the USPSTF initiates are not their responsibility. It is the responsibility of the urologic oncology community and the prostate cancer advocacy community to develop and initiate programs such as these. We have notably failed to do that to date because we have taken the naive approach of assuming that if we screened all men every year it would “solve” the problem of prostate cancer, and that is demonstrably not the case.
As you point out, our collective challenge (which is not the challenge posed to the USPSTF) is to create [better] tests and a system to provide accurate and helpful information and education for men and their families while minimizing unnecessary treatment. The message from the USPSTF (which some appear unable or unwilling to hear) is that, to date, we have a failing grade (in their opinion, which I happen to agree with).
At last … a recognition that there is a difference between PSA screening and PSA testing. How long has that taken?
Every one of the very many arguments about PSA screening has landed up by saying, “Yes, we do need a better way of diagnosing which varieties of prostate cancer are potentially dangerous, but PSA is the best we have, so we need to keep on screening.”
I think that attitude more than anything else has been a major stumbling block in moving forward to diminish the over-treatment associated with screening. Hopefully there will be some movement forward now.
But I’m not holding my breath …
The AUA’s statements following the USPSTF’s recommendations have caused me to completely distrust my urologist, who I know is completely in lockstep with the AUA. This attempt to deflect criticism of screening by changing its name just adds to that distrust.
IMPRACTICALITY OF IN-DEPTH DISCUSSION OF PROS AND CONS
There is a huge problem the AUA is overlooking in the following statement quoted in this article:
“The AUA believes that the decision to test for prostate cancer requires an in-depth discussion of the pros and cons of testing where a patient and his healthcare provider can have an honest and frank interchange and any questions a patient may have can be answered clearly ….”
That huge problem is that it is impractical for the health care provider to have an adequate discussion. Here are the reasons that come readily to mind, but there are likely others:
Time. Such a discussion of pros and cons with follow-up questions and answers takes time, and quite a bit of it. Most likely the setting for this discussion would be the annual or regular physical conducted by the primary care provider. As we all know, time is in very short supply in this setting.
Priority. As the primary care provider decides how to deploy the limited time he has with his patient, there are numerous other medical threats that pose greater risks than prostate cancer. It is arguably irresponsible for the doctor to place such emphasis on prostate cancer.
Knowledge and understanding. It is unlikely that the primary care provider has the knowledge and understanding to give a competent presentation of pros and cons. Many of us have been on the receiving end of that lack of competence in understanding prostate cancer. Moreover, even if the doctor has been keeping up, he or she may have accepted some of the profoundly flawed statements that have been included in the studies and USPSTF recommendations (draft and final), statements that have been echoed in more savvy sources (such as the initial NCCN talking points). A key example is the unsound estimate of the number of screening tests needed to save one life, which is clearly based on results too premature to warrant the assessment.
Patient comprehension. Even if the primary care provider takes the time and does a perfect job of presenting information, many patients are not going to be able to sort through it and come to a good decision, and many will not even want to be involved, preferring to leave that to the doctor. There is also a risk of over-emphasis on the decision to do a PSA test and DRE exam, making a mountain out of a mole hill.
Based on similar suggestions about discussions in the past, I have asked several doctors who treat prostate cancer whether they believed it was practical for primary care providers to have the suggested in-depth discussions with patients, and each of them said such discussions were impractical.
One possible solution would be to use recorded information (written, audio, video, interactive) to make the main points, or have a nurse or assistant fill that role, with the doctor offering to answer remaining questions. That could at least help with the critical time problem.
Here is the solution I prefer: PSA testing with DRE exam would simply be performed, in accordance with guidelines about age, risk, and frequency, after a brief discussion that active surveillance is an excellent option in the unlikely event that prostate cancer is discovered, provided the cancer is low-risk. If the DRE or PSA results generate concern, at that point both the doctor and patient would have greater motivation for a more detailed discussion. I too do not see this working well in a mass screening context.
Addition to my response of 6/13 9:49 PM
ROLE SHIFT during annual (or periodic) physical – Another likely obstacle to that in-depth discussion recommended in the AUA guidelines is the shift in roles of doctor and patient that would often be involved. For most of the exam, the doctor is assessing and giving directions and advice to the patient based on well established knowledge for medically common conditions and illnesses, with the intent that the patient comply. (The “Doc Martin” series comes to mind.) In sharp contrast, the in-depth discussion involves the patient as a thinking partner, ideally a well-empowered partner with the doctor also serving as coach and counsellor, rather than as a fairly passive recipient who is simply supposed to follow through. My hunch is that this difference in roles would often be another obstacle in the way of achieving the recommended in-depth discussion.
I’m thinking the primary care provider community was not represented in the AUA’s development of its recommendation.
GRADE “I” — NOT GRADE “C” — SUPPORTED BY EXISTING TRIAL RESULTS
Kathy:
I’m responding to your comments of 5/30 9:44 am and 1:37 pm in which you suggested that the USPSTF should have assigned to prostate cancer screening, at least in the mass screening context, a grade of “C” — small benefit — rather than grade D.
Unfortunately, even the updated results from the two key trials upon which the USPSTF relied — the PLCO and ERSPC trials, were both premature for assignment of any grade other than “I”, which indicates uncertainty. In essence, the follow-up time from diagnosis in both is too short to illuminate the extent of benefit and will likely remain too short for some additional years. Both trials had a number of other flaws too as far as they bear on the effectiveness of screening.
I am among those who find other evidence persuasive, though not conclusive, that appropriate individually managed “screening” — or “testing” to use Sitemaster’s preferred word — has a potentially large benefit to burden ratio. I see widespread adoption of active surveillance for eligible men as key to reducing the burden part of the ratio.