The following infographic was also issued today by the U.S. Preventive Services Task Force (USPSTF) and offers guidance as to the appropriateness of prostate cancer screening for an average, 55- to 69-year-old American male with no specific, known risk factors for prostate cancer: 
You can also download this graphic directly from the USPSTF web site if you click here.
Filed under: Diagnosis, Risk | Tagged: cancer, infographic, prostate, risk, screening |
THE "NEW" PROSTATE CANCER INFOLINK 
I can only say I was a 55- to 64-year-old male still working when I came down with mine silently. My urologist believes I contracted the disease about age 62 to 64. No special testing indicated or performed during those years, just an old way DRE here and there. I had no known risks. At age 70 it revealed itself with a vengeance.
PCP diagnosed acute prostatitis and prescribed ciprofloxacin and referred me to the urologist whose first blood test performed by a hospital laboratory machine returned a PSA of 1,632 ng/ml. Stunned, he directed a manually performed re-test which returned a value of 1,323 ng/ml. I started bicalutamide that day, and Lupron Depot (90D) 2 weeks later. Last PSA was 6.44 in February, but since it already metastasized to the skeleton years prior and Medicare limitations, we’re fighting a delaying action. No cure possible. I’m still stunned there was no indication of it for 6 to 8 years.
Regarding the USPSTF graphic in the “Is prostate cancer screening right for you?” post, am I to understand that 77 (96.3%) out of 80 who chose surgery or radiation treatment experienced cancer spreading to other organs? Doesn’t sound right.
Dear Jim:
I can’t explain how the USPSTF analysts came up with that specific number. I think you’d have to read the full text of the analysis to understand what you are being told here. (I cannot do that at present because of work pressures.)
However, what I will point out is that of the 80 men diagnosed who went on to have surgery or radiation, it is likely that a significant number already had cancer that had spread to other organs (seminal vesicles, extracapsular extension, lymph nodes) at the time of their treatment.
The flow chart is missing an arrow. What about the 20 that just said no (or at least not yet)?
Dear Mike:
Please feel free to take that up with the USPSTF. We didn’t create this infographic.
Dear Jim S.:
After having had a little time to re-look at the chart and what the USPSTF says in other, related documentation, the answer to your question is no. What the USPSTF is saying is that out of the 1,000 men who go for initial screening, just three men will be prevented from progressing to have metastatic disease (who would otherwise have done so) and just 1.3 men will be prevented from dying of prostate cancer (who would otherwise have done so).
The problem with this infographic is that the benefits and harms are not calculated in similar ways. Hence, the infographic exaggerates the ratio of harms to benefits from either PSA screening or prostate cancer treatment.
The benefits in reduced deaths from prostate cancer or reduced metastatic disease compare the screened group with the unscreened group. These calculations take into account that the baseline in the unscreened group includes diagnoses of prostate cancer and treatment. Screening increases diagnoses and treatment, but not from a zero baseline.
In contrast, it appears that the harms of erectile dysfunction and urinary incontinence compare the screened and treated group to a group that has a zero rate of being diagnosed or treated for prostate cancer.
This is clearly comparing apples and oranges.
The USPSTF seems to systematically have a problem with getting ratios of benefits vs. costs right, and being inconsistent in what thought experiment they are running. This is very surprising to me because obviously the organization’s staff has researchers who should be aware of these issues.
Vitally Important Improvements Needed in the USPSTF’s Misleading Graphic “Is Prostate Cancer Screening Right for You”
Despite the important negative points below, the chart is a great improvement over the woeful and inept, ignorant portrait of prostate cancer presented by the 2012 version of the USPSTF. The current USPSTF merits credit and appreciation for that. However, these changes should be made (in addition to reworking as Dr. Bartik suggested):
At the second level down – 240: The chart fails to note that findings that turn out to be BPH or infection/inflammation often also have value for the patient’s quality of life, though not regarding cancer. The USPSTF still fails to recognize that PSA is a multipurpose sentry and highly effective when all its roles are considered. Infection/inflammation is a burdensome issue for many men as is BPH; earlier awareness of both opens opportunity for more effective treatment.
This level also shows potential side effects of biopsy. However, the main problem is that too little information is provided, specifically the very low rates of these three problems, known measures that further reduce these already low risks, the rather minimal and short-term burden typically associated with pain and bleeding when they occur in a good practices setting, and the effectiveness of available treatments. At the least this added information should have been conveyed in a footnote. The unfortunate impact of providing this incomplete information that is skewed toward discouragement of having a biopsy is that some men who should have been screened and gone on to a biopsy will neglect to do so, likely many thinking this chart has informed them well enough that they need not even bring up the question with their already too busy general practitioner.
The note on biopsy should be accompanied by another note on the growing use of mpMRI to determine whether a biopsy is needed; indeed, the PRECISION trial reported by Sitemaster today indicates that mpMRI use can reduce the need for a biopsy by about 28%.
At the third level down – 100: It is outrageous that the USPSTF still fails to highlight the critical and extremely effective role of active surveillance in minimizing unnecessary treatment, especially as acceptance of active surveillance continues to grow rapidly, even reaching 72% (together with watchful waiting) in the VA care population in 2015 per Sitemaster’s recent report. This is a monumental missed opportunity for the USPSTF to pass on truly useful information, and I hope they will correct this egregious flaw! It is not enough that they mention active surveillance on the next level with what appears to be a now obsolete low figure for those electing active surveillance.
At the fourth level down – 80: The main flaw here is in the footnote which indicates that 65 of the 80 will choose immediate treatment while 15 (19%) choose monitoring. I strongly suspect that 19% figure is obsolete; at the least the table should include a phrase indicating that this proportion is increasing rapidly and is probably now in majority territory for those eligible for deferred therapy. Secondly, the footnote for the 15 on monitoring also states: “monitor their cancer initially and later have surgery or radiation when it progresses.” As it appears that more than half of men who defer treatment will never need treatment, per a lot of research, that sentence cries out to be amended to: “monitor their low-risk cancer initially and later have surgery or radiation if ever and at the time it progresses, with more than half never needing treatment, and with the rest typically gaining years free from side effects, with deferred treatment effectiveness equal to that of immediate treatment.”
At the fifth level down: 3 – 1 – 5: The USPSTF still does not grasp that presenting data as a snapshot when results are dependent on follow-up time (and also screening quality) is highly misleading. The phrase “at least” should be inserted before the 3 for metastasis and before the 1 for death from prostate cancer. The footnote should state that the benefit trend is sharply improving as trial follow-up lengthens, which we have seen twice now in the only trial that really bears on this point, the ERSPC. The 5, for deaths from prostate cancer even after treatment, is misleading and defeatist as it fails to include the fact that treatment has been proven to extend lives, often by years if not many years, no doubt extending quality time, before these patients die. This needs to be reflected in the dark blue block, in the footnote, or both. It is perhaps too much to expect that the USPSTF would recognize that research is rapidly improving the armamentarium for later stage patients, a fact which will lead to even greater extension of quality years of life than current treatments.
I will try to communicate these needed improvements to the USPSTF, though I’ll look at any comments first.