The screening/testing debate is alive and healthy!

An open access (i.e., full text) article just published in BMC Medicine provides us with a detailed discussion of the current state of the PSA-based “screening/testing” debate as seen from the differing perspectives of a number of academic experts on this topic.

This new article by Carlsson et al. actually comprises an introduction, followed by a series of question and answer conversations between Sigrid Carlsson and Andrew Vickers (as the lead “editors” of the article) and seven other authorities divided into three groups:

  • A “pro-testing” group, which includes Michael Leapman, Peter Carroll, and Fritz Schröder
  • Ab “anti-testing” group, which comprises Peter Albertsen and Dragan Ilic
  • A “decision-analytic” group, which is made up of Michael Barry and Dominick Frosch

The article concludes with a “Discussion” in which Carlsson and Vickers give their shared perspectives on the differing points of view of the interviewees.

Now we should be clear up front that none of these authorities holds an absolutist “pro-screening” position — and by this we mean that none of these authorities is in favor of mass, population-wide screening of all men of between 45 and 75 years of age on an annual or other frequent basis. In fact, it is becoming very difficult to find anyone who still holds such a position today. Equally, only one of them favors the position taken by the U.S. Preventive Services Task Force in 2012 — i.e., that the PSA test should not be recommended as a tool to assess risk for prostate cancer in any asymptomatic male.

The differences in perspective between the various experts (with the single exception of Dr. Ilic) are actually highly nuanced and seem to be closely congruent (in many ways) to the position long held by The “New” Prostate Cancer InfoLink … that mass, population-based, annual screening of all men is not really a very good idea but that use of the PSA test to help to assess risk based on a range of known risk factors appears to be valuable — even though there are still details to be worked out, and we don’t yet have a consensus on how best to do this.

We are not going to provide a summary of this article, because the nuances and the precise ways that the different contributors express their opinions about the issues are actually crucial to understanding why they hold the opinions that they do. Interested readers are encouraged to read this article for themselves. The thing that almost everyone clearly agrees about, however, is that the days of “black/white” discussions about screening (of everyone on a regular basis) or no testing at all should now be long past. The questions today need to be focused on how better to determine

  • Who is at real risk for clinically significant prostate cancer and therefore needs to be assessed for the actuality of that risk on a regular (albeit still undetermined) basis
  • Who is at very limited risk and may only need to have that risk assessed a few times in his lifetime (say at ages 45, 55, and 65) and
  • How best to minimize the risk for over-monitoring and over-treatment of men who are diagnosed with what appears to be favorable-risk disease that is unlikely (for a variety of possible reasons) to become clinically significant during the patient’s lifetime

You will note the inclusion of the idea that we need to minimize risk for over-monitoring. One of our concerns today is the potential for excessive and unnecessarily frequent biopsies of men with low- and very low-risk prostate cancers. While active surveillance appears to be an excellent way to monitor the need for further care for a significant percentage of men diagnosed with favorable risk disease, excessive biopsies themselves come with risks that we should be trying to avoid (particularly including the risks for effects on sexual/erectile function and for severe and/or chronic infections).

11 Responses

  1. It’s the biopsy that leaves me wondering, what if the biopsy is the reason for all the relapses? How can anyone be really sure that the needle doesn’t drag a little cancer out to run free, or that the hole squirts a little after the needle has withdrawn?

  2. Dear PV Lady:

    This comes up over and over and over again. But think about it. There was been a massive increase in the number of biopsies that get carried out each year in the U.S. after the expanded use of the PSA test in the early 1990s through to today. However, there has also been a roughly 40% decrease in the numbers of men who die of prostate cancer over the same time frame.

    If there was a significant likelihood that prostate biopsies led to spread of prostate cancer, then we should have been seeing a major increase in prostate cancer mortality rates over this time frame.

    While it is absolutely true that “tracking” of prostate cancer cells through the prostate can and does occur after some prostate biopsies, the ability of those cells to grow in their new environment is extremely low indeed because the new environment is not conducive to such growth. It is actually extremely difficult to take prostate cancer cells from their original environment and move them to a new environment and get them to grow. This is one of the reasons that, by comparison with the incidence of localized prostate cancer, the incidence of metastatic prostate cancer is so much lower.

  3. @PVlady:

    To reiterate Sitemaster’s response, please see his excellent entry from August 2014 — “Needle tracking of prostate cancer cells during prostate biopsy: a review” and the ensuing discussion where he suggests risk may well be less than 1 in a 1,000.

  4. (a) For prostate cancer screening, where around the Web are there lists of alternatives to the endorectal coil … to ask about at the urologist/radiologist/MD before 3 tesla multiparaMetric magnetic resonance imaging, i.e., a list to go over with the MDs.

    (b) What alternatives to an endorectal coil might be used? … An online list for patients/MDs could be compiled if not already available.

    Depending on what procedure is used the position of the prostate could be changed.

  5. Dear Thezak:

    Pelvic 3-T mpMRIs can be given today without the use of endorectal coils, but I know of no list of centers where such scans are available.

  6. I appreciate your responses and I am trying to believe what you said. Sounds like cancer escapes on it’s own all the time, that shows in the PSA, so a little help from the needle isn’t a worry. … it’s a very fussy critter that doesn’t make a nest easily.

    I’ve been reading in several sites that recurrence is actually 40% in 2 years, here’s a quote, “Dr Otis Brawley, Chief Medical and Scientific Officer and Executive Vice President of the American Cancer Society. was quoted in The New York Times on April 4, 2002, as saying that 40 percent of men will have a recurrence within two (2) years”.

    Also the Harvard Health Publications say recurrence is as high as 70% in cases in which the PSA doubling time is high. But they also say that recurrence is 40% for Gleason 7, PSA greater than 10, lower than 20.

    This report discusses the endorectal coil.

    Trying to learn. This is a complicated subject. But it’s encouraging how much they have advanced in a very short time.

  7. Dear PV Lady:

    The risk for prostate cancer recurrence in a specific patient after first-line treatment for localized disease (if treatment is actually necessary in the first place, which it often isn’t) depends on a whole variety of factors, including but not limited to the patient’s: clinical or (better if available) pathological Gleason score; clinical or (better if available) pathological stage; PSA level at diagnosis; nadir PSA level post-treatment; PSA doubling time post-treatment; the presence or absence of positive surgical margins, extracapsular disease, positive seminal vesicles, and/or positive lymph nodes; and the genetic make-up of the actual cancer.

    As a consequence, projecting risk for recurrence in any individual patient is a complex issue. A wide variety of nomograms are available to patients and their doctors to help them assess their risk for recurrence. One of the better examples of this is the post-surgical nomogram on the Memorial Sloan-Kettering Cancer Center web site.

  8. Added Note to PV Lady –

    Many recurrences are real but so mild that they need no treatment and pose no threat to life or well-being. (Johns Hopkins is one of the centers that has published about that.) Many others are moderately threatening but can be countered with various mild and easy tactics (such as quality pomegranate juice or extract pills consumed regularly for years; a statin drug, metformin, nutrition and diet, exercise, etc.). Some recurrences are challenging.

    You might also want to check some highly encouraging study results for radiation treatment at excellent facilities.

    Good luck!

  9. Highly Interesting Paper

    This was a fascinating paper, thanks for the link!

    I suspect one of the reasons I like this paper a lot was that the thinking of Vickers and Carlsson (and most of the others, clearly excepting Dr. Ilic, as Sitemaster noted) ring true. Here are a few initial thoughts.

    At least one doctor still puts some trust in the results of the PLCO (Prostate, Lung, Colo-rectal, and Ovarian) trial as a screening trial with meaningful results on the efficacy of screening, even though that is not a tenable position for people who are informed and think without the blinders of bias and preconception. Vickers and Carlsson neatly expose the fallacies and draw the right conclusions: PLCO results are not useful as a screening vs. no-screening trial (which it wasn’t, as they note). Once you eliminate PLCO, the meta-study that included PLCO as a large component also becomes meaningless, yet is still relied upon by at least one of the skeptics.

    It is encouraging that even the skeptics of the worth of screening are acknowledging the latest, 13-year (from enrollment) update of the European Randomized Study of Screening for Prostate Cancer (ERSPC), which shows an increased benefit from screening. However, some are still seeing those results as a snapshot rather than as a markedly favorable trend in screening’s favor with just a few years of added follow-up. The experts favoring screening also noted that adjusting the trial results for non-participation in the assigned group substantially reduced the mortality relative risk figure (from 21% lower than non-screening to 27% lower than non-screening. (They could have noted further important facts, such as that Belgium ran out of funding for screening, that most used a 4-year interval rather than a 2-year interval as in Sweden, and other facts that further boost the favorability of screening.)

    Some of the skeptics still doubt the value of treatment of prostate cancer. That would be amusing if it were not so sad and discouraging! Dr. Albertsen, a prominent urologist in Connecticut, was woefully unaware of studies regarding the efficacy of radiation.

    On the critical issue of how men become informed, Vickers and Carlsson put some emphasis on what they refer to as a “behavioral” as contrasted with a “preference” approach. In simple terms, the “preference” approach relies on a detailed listing of pros and cons of screening, which often even now employs obsolete data that does not reflect the current and growing value of screening as indicated by the ERSPC trial, as the pair notes. Indeed, they do a marvelous job of showing how daunting, highly complex, and obscure an adequate pros and cons approach would be (page 16 of 17, second column). Instead, they advocate use of active surveillance to minimize over-treatment and limiting screening in older men (page 14 of 17, second column).

    The pair also comes down emphatically on the side that use of active surveillance has increased greatly in the US and is rising. It is clear that at least one of the doctors they interview has not kept up with studies documenting that trend.

  10. Dear Jim and PVLady:

    Since your conversation about radiation therapy and pomegranate juice has now become a personal issue of no interest to others at all, I have deleted the last two comments and closed further comment on this topic.

  11. Dear Jim and PVLady:

    Since your conversation about radiation therapy and pomegranate juice has now become a personal issue of no interest to others at all, I have deleted the last two comments and closed further comment on this topic.

Comments are closed.

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