Legal risk for physicians and use/non-use of PSA testing

Dr. Gerald Chodak has raised an interesting reason why physicians may want to think hard about the U.S. Preventive Services Task Force’s recommendation on the value of PSA testing for risk of prostate cancer.

In one of his regular commentaries on the Medscape web site last Friday (under the heading “PSA screening: are we ‘falling backwards’?“), Dr. Chodak expresses a concern shared by many in the prostate cancer advocacy community (and by many urologists too) that the USPSTF recommendation may lead — over the next decade — to an increase in the numbers of men in America who get diagnosed with non-localized and metastatic forms of prostate cancer, compared to the levels seen in about 2012. This is a justifiable concern.

The USPSTF’s recommendation that widespread PSA screening is not justified by the available data is often — unfortunately — boiled down to a simple, “Do not use the PSA test to screen for prostate cancer.” This is not actually what the USPSTF stated, but it may well be what a lot of people (physicians included) think the USPSTF said because it is what they have heard.

What Dr. Chodak points out is that not giving men PSA tests when they might benefit from such tests is going to come with significant legal risks for physicians. Sooner or later, some men who are not given PSA tests, and who then get diagnosed with advanced or metastatic prostate cancer based on symptoms alone, are likely to take legal action against doctors who did not either give them or at least offer them a PSA test at a time when that cancer might have been identified earlier and then treated with curative intent.

The general consensus across the urology, oncology, and patient advocacy community today — and among many in the primary care community too — is that each man and his doctor need to have a conversation about risk for prostate cancer and whether the patient wishes to have a PSA test or not. Dr. Chodak’s premise is that, given that consensus, what physicians really need to do is something like the following:

  • Make sure each appropriate patient is advised about risk for prostate cancer in general.
  • Discuss with the patient any specific  and relevant risk factors (family history, race, age, etc.) that may place him at greater than average risk for clinically significant disease.
  • Discuss with the patient the pros and cons of PSA screening and the potential consequences of PSA testing (specifically including the risks associated with prostate biopsies and over-treatment of low-risk prostate cancer).
  • Ask the patient whether he wants to have a PSA test, and establish, if possible, whether the patient has a preference one way or another. (Note that in some cases it may be highly appropriate for the doctor to recommend a PSA test or even insist on one.)
  • Document this conversation in the patient’s records so that it is quite clear that the patient was made fully aware of the opportunity and given the chance to express his preferences.

Whether any one individual patient should or shouldn’t actually be having regular PSA tests is a complex issue. Some certainly should; others may never need a PSA test any more than (say) every 5 years through age 65 or 70. These decisions really need to be individualized.

Not telling a male patient aged between 40 and 75 years of age about the existence of the PSA test and his possible risk for prostate cancer will almost certainly become a serious legal problem for one or more doctors at some time in the not too distant future. It may be even more of a problem for some of the patients to whom they fail to offer the test. For physicians treating male African American patients here in America,it is more than twice as likely to become a serious legal problem.

If you want to read or listen to Dr. Chodak’s original commentary, you will need to register as a member of the Medscape website. There is no cost involved to do this.

8 Responses

  1. A Better Approach Than the Pros and Cons Discussion: Educate About the Role of Active Surveillance!

    I see a time coming when the medical community will focus instead of pros and cons — especially a badly mangled presentation based on deeply flawed understandings — rather on a man’s understanding and comfort with the now well-supported strategy of active surveillance for appropriate low-risk prostate cancer.

    Communication about active surveillance and its high effectiveness as a way to avoid over-treatment while ensuring appropriate, timely treatment is simpler, better targeted to the concerns and attention range of an apparently healthy patient, and much less time-consuming than a pros and cons discussion with a then supposedly healthy man. If a man is otherwise suited for screening — no serious conditions, with reasonable life expectancy, etc., and he is comfortable and understands active surveillance, should he be diagnosed with low-risk disease that suits active surveillance, why not just go ahead with the PSA test, or even better with the DRE also?

    The detailed discussion of pros and cons of biopsy and alternatives/complementary tools (such as multiparametric MRI, color Doppler ultrasound) can come later and as needed for the much smaller proportion of screenees with results that raise concerns that are not explained by BPH and infection, which of course are the other major possible positive revelations of PSA screening and well worth knowing about. That is the time when the discussion will have the full attention of the patient! Dr. Mack Roach, MD, the well-known radiation oncologist from UCSF, raised a similar model of communication on screening in his presentation to the 2013 conference on prostate cancer in Los Angeles.

    The early embrace of a pros and cons discussion by leading prostate cancer organizations came at a time when many in the medical community had not thought critically about the profoundly premature and flawed data relied upon by the US Preventive Services Task Force. Updates to the more reliable trial, the ERSPC, have demonstrated an advantage to screening that grows substantially with each additional 2 years of followup, especially in the cohorts that matter most — the Netherlands, Belgium, and Finland cohorts. I’ll bet that many doctors are still relying on those early reports from 2009 in giving to their patients misleading reports of harms coupled with an equally misleading — now demonstrably false =- absence of benefits.

    All this said, Dr. Chodak is providing valuable leadership in encouraging American physicians to at least give their patients some chance to get valuable prostate cancer screening.

  2. Sorry for being cynical, but after all the debate, we now arrive at a CYA policy for screening.

  3. PSA saved my life at age 46! Without it I wouldn’t have known that I had a Gleason 7 (4 + 3) that originally I was told was a 6 on biopsy and is slow growing so don’t worry. Wrong! My second Doctor at Johns Hopkins said “You had the real deal” when the surgical path came back.

    My opinion: every American male citizen at the appropriate age deserves a PSA. How to manage the results is a different story.

  4. Not only should every doctor have this discussion, but every doctor should understand that PSA velocity is more important than PSA level and they should know if any meds being taken impact PSA levels. Simply relying on an ”acceptable” PSA number for each age group is not adequate.

  5. I addressed this very issue in the closing paragraph of my article “PSA testing? Over-treatment?” Active surveillance? Biopsy value? No PSA for elderly?” way back when the USPSTF came down with their ruling against PSA testing. Good for Dr. Chodak to now also bring up this important consideration for physicians.

  6. I think that both the PSA and free PSA are valuable tests and a baseline should be a part of every man’s physical exam. Every man is different and unique. My brother had normal PSAs in every instance but when his urologist drew a free PSA it was very abnormal. He also had a palpable mass in his prostate upon digital exam. I have the background of a medical specialist and a huge family history for prostate cancer from my mother’s side of the family. My PSAs were always normal and so were the free PSAs. Nothing was felt on the prostate by two different urologists. I insisted that we do a 12-core biopsy, which my urologist agreed with. All of the prostate cancer in my family began around ages 65-70. The biopsy came back showing adenocarcinoma of the prostate in two adjacent areas on the left side, with the right side apparently free. Currently Dr. Carl Rossi at Scripps wants to see a 3-tesla MRI-guided 24-core biopsy so he can get a more in depth look at cellular pathology. Depending on the biopsy results he will either elect to wait and watch or begin proton therapy at Scripps in San Diego. I’m single and have a active sex life so I’d like to save my potency if at all possible.

  7. A Question for Dr. Chodak – Initial Urology Community Docile Response to USPSTF

    Thank you Dr. Chodak for pressing this issue.

    Do you have any insight as to why the urology community and other guideline groups accepted the USPSTF recommendation with such a docile reaction when finally published a few years ago? I was quite surprised that the community did not point out that the critical mistakes in the Task Force’s reaction to and interpretation of the two key studies, the PLCO and ERSPC trials, especially the gross prematurity of follow-up in the trials from time of diagnosis as published in 2009.

  8. From my experience and that of a couple other fellows I know, I think the best course is to have a PSA with an open mind about active surveillance (AS) if that is a viable option. I had a PSA of 3.76 and a positive diagnosis of Gleason 3 + 4 in one biopsy core a little over a year ago and have been on AS since. So far so good; last PSA dropped to 3.0, and an mpMRI showed no evidence of any cancer. Within a 60-day time frame of my diagnosis, two of my high school classmate friends were diagnosed, one with a Gleason score of 4 + 3 and PSA 25, the other with a Gleason score of 9 and PSA 10. Both of them had treatment. Obviously, had they not had the PSA test, the future would have been bleak.

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