“Five golden rules” for prostate cancer screening and treatment today

In a very simple and straightforward article in European Urology, Vickers et al. have clearly laid out a series of five “golden rules” that, in their opinion, all physicians should be following today when they are testing men for risk of prostate cancer through the use of the PSA test.

One of the key points of this article is built into its title: “It ain’t what you do, it’s the way you do it: five golden rules for transforming prostate-specific antigen screening.”

The full text of this article is available on line, and we strongly commend this article to all support group leaders and other prostate cancer educators. Its recommendations make perfect sense to The “New” Prostate Cancer InfoLink, and would clearly help us all to separate the concept of testing for risk of prostate cancer from the dangers of over-treatment, which simultaneously would help us to minimize the risk of over-diagnosis in inappropriate patients.

The five golden rules laid out by Vickers et al., all five of which are based on a great deal of recent research data, can be sumarized as follows:

  • Golden Rule 1: “Get consent” from the patient before you give any PSA test.
  • Golden Rule 2: “Don’t screen men who won’t benefit” (e.g., men of 80+ years of age with multiple co-morbities).
  • Golden Rule 3: “Don’t biopsy without a compelling reason” (i.e., don’t just biopsy every man with a PSA of 3 ng/ml; do a work-up first to see if a biopsy is justified by other simple tests like a DRE or a %free PSA test or just a repeat PSA test).
  • Golden Rule 4: “Don’t treat low-risk disease” (unless there really is a good reason to do this, because such men can be safely managed initially by active monitoring).
  • Golden Rule 5: “If you have to treat, do so at a high-volume center”.

The last of these five golden rules may well upset a lot of urologists — but from a patient perspective it is a really good general rule to follow!

Read the whole article for yourself. It’s short and to the point, and it’s well worth the 5 minutes it will take you!

It is also worth noting that this article is highly supportive of another recent, full-text article, by Loeb et al., in European Urology, entitled simply “Overdiagnosis and overtreatment of prostate cancer.”

6 Responses

  1. A PROBLEM WITH: “1. Golden Rule 1. Get consent”

    The Vickers paper states:

    … we believe that doctors should not order a PSA test, perhaps unique among blood tests in terms of its downstream consequences, without, at the very least, informing the patient about the uncertain balance between the benefits versus harms, providing a rationale in terms of why screening could do more harm than good for that individual patient, and obtaining explicit verbal consent before proceeding to order the PSA test.”

    I still have some hope that more of us in the community will come to a different view of presenting the value of screening to men: rather than stress controversy and acting like we are very uncertain about benefits of screening, let us say that, if you, the prospective person to be screened, are comfortable with active surveillance as a great option for low-risk prostate cancer, your risk of over-treatment is very low, provided any biopsy, if needed, is done with appropriate anesthetic and bacterial prevention techniques, and that your benefits of avoiding not only death from prostate cancer but also major symptoms and complications of the disease are high. Yes, the prospective screening candidate should be informed that there are often side effects from treatment,if ever needed, but that these are worth while if there is a likelihood of serious disease and the treatment minimizes that likelihood.

    Regarding the harm and good of screening, I am appalled that so many physicians and reporters are relying on the profoundly flawed analysis of the US Preventive Services Task Force which in turn relied on a snapshot from the ERSPC: the 11-year follow-up figure that about 1,000 men (1,055 to be precise) would need to be treated to save a life. The reality is that that study was still very premature (and flawed) at that point in terms of survival after diagnosis of prostate cancer, that it showed a far higher treat-to-benefit figure when initially published with just two fewer years of follow-up (1,410) — evidence of the sharp downward trend with increasing follow-up that many of us critics expected, and that with nearly two more years of follow-up (12.8) from the 11-year results, the Netherlands group (Rotterdam), the second largest contingent in the ERSPC at roughly 20% (next to Finland at roughly 50%) showed “Correction for noncompliance at initial screening resulted in PCa mortality reduction of 33%” for men in the screening group compared to the control group, a figure far higher than the initial ERSPC figure. Numbers needed to invite to the trial and to manage are 565 and 33 (55 to 74 years of age) and 392 and 24 (65 to 69 years), but I’m not sure how those relate to one saved life due to screening. I suspect they have a relation and are a further substantial drop from the figure of about 1,000 that is quoted these days.

    All this said, I favor getting consent, but after the kind of orientation I’ve indicated instead of an intimidating lecture founded on faulty fact and analysis.

  2. AN ISSUE WITH Golden Rule 5: “If you have to treat, do so at a high-volume center”.

    That sure works for me if the patient is focused on surgery. The issue I have is that the paper addresses only surgery, not even mentioning radiation. A lot of us, including me, consider MODERN radiation with its supportive imaging and targeting, to be at least the equal of surgey and likely superior where risk is elevated.

    This is my second and likely last comment, so I’ll add here that, while I would not have made my comments unless I considered the issues raised important, I generally like these five rules very much.

  3. Dear Jim:

    I don’t know where you are getting the “intimidating lecture” from. All I would expect a physician to have to say is something like, “The question of whether the benefits of regular screening for risk of prostate cancer with a PSA test outweigh the risks related to such screening and the consequent risks associated with treatment is not yet well resolved” and that “Some doctors and patients believe the benefits outweigh the risks, especially when the potential for simple monitoring of low-risk prostate cancer is taken into account. Others are less certain about that.”

    What you can not argue with is the fact that the role of PSA testing is (and actually long has been) controversial, and it is still unresolved. That’s all Vickers and his colleagues want to make sure that patients appreciate. After that, patients can make their own minds up.

  4. The article by Vickers is a step in a positive direction but I take argument with rules 2, 3 and 4.

    Not screening men that are unlikely to benefit is a great idea but defining that group as 80+ will include far too many in the unlikely to benefit category. Absent is the fact that in the two treatment randomized studies done (Scandinavian and PIVOT) men over 65 did not yet benefit from treatment at 12 or 14 years. That would mean at best, men need more than a 12-14 year life expectancy and very few men at age 70 pr 75 will meet that number. They should have avoided age in their paper and simply talk about life expectancy.

    Rule 3 is a problem because having a normal rectal exam does little to help decide about a biopsy, nor does using free PSA, whose value is for deciding about doing a second biopsy if the first one is negative. Also, even a repeat PSA will result in many men remaining unchanged at the level of 3-4 ng/ml. They should have added a statement about PSA velocity.

    Rule 4 will be a huge problem without talking about a man’s age because men who are under 70 or their partner will have psychological issues that will result in treatment.

    So while providing some helpful info is a great idea, number one is really the best and it should include the odds of benefiting or being harmed.

    A final word about the US trial. The study indeed had considerable contamination, but there was a large enough difference in screening rates between the two groups to detect a significant difference in mortality if a significant difference existed.

  5. Dear Dr. Chodak:

    With great respect, I think that you are imputing overly-specific directives to the proposals of Vickers et al.

    With respect to rule 1, they (and I) give “men of 80+ years of age with multiple co-morbities” as an extreme example, not a specific recommendation. One could reasonably argue that, based on the same “golden rule”, one shouldn’t be screening men of any age with a life expectancy of < 10 years (but of course we are all — laypersons and professionals alike — notoriously bad at projecting life expectancy for an individual, so how could one do that with accuracy?).

    With respect to rule 3, Vickers et al. give examples of things that could be done to further assess a patient’s risk. If the patient got two more PSA tests done (preferably at the same laboratory) prior to a decision about a biopsy, then there would be sufficient data to calculate his PSA velocity. However, it has to be said that the value of PSA velocity as opposed to a PSA value at a point in time is still a controversial question. Vickers and his colleagues would probably argue, with some justification, that it is the most recent PSA value that is important and not the velocity.

    Finally, with respect to rule 4, of course one has to take a patient’s age into account, right along with his family history, and his degree of angst about his risk. I don’t think for a moment that Vickers et al. are suggesting otherwise.

    What Vickers et al. are telling us is that it is the physician’s mindset that is important in all of this. Is s/he determined to find any amount of cancer at all costs or is s/he trying to help the patient understand and manage his actual risk for clinically significant prostate cancer? If I was the patient, I would very much hope for the latter.

  6. When I was 44 years old, I had my first PSA test. It came back at 20 ng/ml. When told, my reply was, “What’s a PSA test?” That should not happen. Even though I benefited highly from the testing, I should have been made aware that I was being screened. After I was told my result, I had to ask, “Is that high?”. Again, I think it is imperative that men know they are being tested. Women know when they are screened for breast cancer and cervical cancer. You can’t keep a mammogram or an action by a OB/GYN secret.

    It should not be difficult for a doctor to talk a bit about why the need for test, what’s good and bad about it, and that it is appropriate for every man to learn about prostate cancer — whether the man has prostate cancer or not.

    I think Vickers’ points are valid, but again these “guidelines” do not cover every man or every situation. Screening is a right for a patient, I believe, but it should be an educated patient. However, there will always be someone slipping through the cracks. No matter what guideline you look at, someone is being missed or skipped. It’s more important for men to be educated before their prostate cancer journey begins.

    How? That is a real good question!

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.

%d bloggers like this: