My email exchange with Dr. Otis Brawley (ACS chief medical officer) re PSA screening issue

I first heard of this study (recommending against routine PSA screening) yesterday morning, when Dr. Otis Brawley, chief medical officer and executive vice president of the American Cancer Society, appeared on CBS This Morning with Charlie Rose. Hearing Brawley's explanation of his position (against routine PSA screenings), I was moved to write to him. I called the ACS and obtained his email address.

Below is the email I sent him yesterday, and the response I received moments ago.

My email:

Dr. Brawley,

I write in the hope that you can help me better understand the views you expressed this morning on CBS TV with regard to routine PSA screening for men. I am a brand new prostate cancer survivor, having been diagnosed in February (at the age of 58) and having had robotic assisted surgery just thirteen days ago. My cancer was discovered as a result of a routine PSA test followed by a prostate biopsy.

Unless I misunderstood your remarks, you appear to be of the opinion that routine PSA screening is not advisable because it could lead to unnecessary treatments that may do more harm than good, some of which may lead to death. Rather, you say that the option to undergo a PSA test should be discussed with a physician on a case-by-case basis, with all of the pros and cons being explained. (If I misstate your opinion, I apologize. One of the reasons I am writing is in order to ensure that I heard your message correctly.)
Assuming your position is as described above, I find it to be illogical and, quite frankly, disturbing. I’m sure you will agree that the PSA blood test in and of itself —the simple drawing of blood and the analysis of that blood sample by a laboratory—poses no health risk to the individual. Rather, you say that once the test has been performed, and an elevated PSA level is detected, decisions made at that point may lead to unwarranted treatment and undesirable results.

Would it not make more sense for the physician-patient discussion that you advocate to take place then, at a time when both have learned of the elevated PSA? Your approach ensures that all men of a certain age would face unnecessary anxiety, wondering whether they carry a ticking time bomb. Worse still is the possibility that a growing cancer will go undetected.

If an elevated PSA is an indicator of possible prostate cancer, is it not more logical to know this when making decisions with one’s physician? I realize that one may have a “normal” PSA level but nevertheless have cancer, but it seems to me that knowing as much of the facts as possible when contemplating different courses of action makes the most sense.
Among the things that Digger Phelps said during the CSB segment was that he feared that without a routine PSA test, many men would simply never have the discussion with their physician that you advocate. I agree. However, faced with an elevated PSA level discovered in a routine test, those men are more likely to “sit up and take notice.”

You said: “I think we need to actually tell men there are risks to this test. There are scientifically known risks.” It is not the test that is risky. It may be the actions taken after the risk-free test shows an elevated PSA level that may be risky. The time to discuss those risks is after the test. Even if the routine test shows a normal PSA level, the patient and physician can then discuss all of the pros and cons of what to do next.

I think we’d both agree that all men of a certain age must be made aware of the possibility of prostate cancer and that all men must discuss this subject with their doctors. But that discussion must be had with knowledge of as much of the relevant facts as is possible. Continuing routine PSA screening ensures that doctor and patient have that pertinent information. Eliminating such a routine test unduly exposes a large segment of the male population to the risk that this discussion is never had.

Again, if I have misunderstood your opinion, I apologize and I ask that you kindly explain what I misconstrued. If I have stated your position correctly, I ask that you address the concerns that I raise above.

Thank you.
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Dr. Brawley's response:

Hi thanks for the email. Thank you for the demeanor of your email. I appreciate calm reasonable conversation and welcome the chance to communicate even if we end up disagreeing.

You understand my opinion which is that the conversation should occur within the physician patient relationship and before screening occurs. The test is so unpredictable indeed 70 to 80% of men who have an abnormal will not have prostate cancer. There are studies to show that chasing the reason for the abnormality has an emotional toll. These guys even have a higher than average suicide rate. Some have relationship and job issues after an abnormal test and no cancer found etc.

I am attaching the current recommendation of all organizations I know of. You will note that no organization says screen then discuss. All either say the test are too unreliable so do not use it or inform before screening. Indeed the Task Force is not the only group saying that we should not be screening.

The issue is screening causes a cavalcade of medical interventions which I believe but do not know saves some lives. At the same time I know it leads to the early death of 1000 to 1200 men per year in the U.S. The operative words are believe and know.

I am especially outraged about mass screening which is part of the business plan of so many hospitals in the US. At a time when we do not know if screening saves lives we know its lucrative. Few mass screening programs tell men anything about known proven harms and theoretical benefits. It is known beneficial to the institution offering the screening.

Keep in mind that 60 percent or more of men who get treated for a screen detected tumor would do fine if never told of the disease not just never treated. We need a test to discern who those guys are then we can actually see if our current treatments benefit anyone. The only clinical trials that show a benefit to screening show that less than 5% of men treated benefit if that many. It may be one to two percent with treatment killing one percent.

At the same time a substantial proportion of men treated have serious side effects of treatment that are often life threatening. I am concerned about the number of men who are deceived into thinking this test and prostate cancer treatment is better than it actually is.

Again the recommendation of experts (not Otis Brawley are below) Note I really like the AUA published recommendation below and find it interesting that they were so harsh in their press conference this week. I have also attached my CNN piece for this week and a copy of my editorial as published in Annals of Internal Medicine where I talk about the Task Force.

www.cnn.com/2012/05/22/opinion/brawley-prostate-screening/index.html?hpt=he_c2

I would be happy to continue this conversation. I learn from such.

Thanks

O

The statements of numerous professional organizations summarized below indicate that there is a problem with PSA screening and caution should be recommended before advocating everyone get it.
Currently recommending against PSA screening
• U.S. Preventive Services Taskforce
• Canadian Taskforce on the Periodic Health Examination
• American College of Preventive Medicine
• American College of Physicians
Currently recommending for informed decision making
American Urological Association (the published written statement of the organization which I agree with seems to differ from what was said at the press conference on Monday). This was first published in as PSA Best Practice Statement 2009.
Given the uncertainty that PSA testing results in more benefit than harm, a thoughtful and broad approach to PSA is critical.
Patients need to be informed of the risks and benefits of testing before it is undertaken. The risks of overdetection and overtreatment should be included in this discussion.

European Association of Urology
• Recommend for informed decision making within the physician-patient relationship.
• Recommends against mass screening.
“Men should obtain information on the risks and potential benefits of screening and make an individual decision”

The National Comprehensive Cancer Network 2010
“There are advantages and disadvantages to having a PSA test, and there is no ‘right’ answer about PSA testing for everyone. Each man should make an informed decision about whether the PSA test is right for him.”
The American Cancer Society 2010 Prostate Cancer Screening Guideline

“Men should have an opportunity to make an informed decision with their health care provider about whether to be screened for prostate cancer, after receiving information about the uncertainties, risks, and potential benefits associated with prostate cancer screening.”

Otis W. Brawley, MD, FACP | Chief Medical & Scientific Officer
American Cancer Society, Inc. | Professor, Emory University
250 Williams Street NW, Atlanta, GA 30303 | cancer.org

404.329.7740 | fax: 404.329.7530

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Would it be appropriate to include Dr. Brawley's email address? He might appreciate hearing from some of us who don't share his opinion.

Good point, Ed, though I thought it was only us PSA screening advocates who are close minded

I find Brawley's email insulting.

I'd also like to know if anyone here buys the fact that we become suicidal when we hear that our PSA is elevated and that we might need a biopsy.

If 60% would do fine (debatable anyway), what does that say about the other 40%?

And how about really young guys like me who get cancer before 40 and find out about it at 40? What does his 15-20 year study data from 2 European studies say about that?

I also feel the Dr.  is wrong. By watching my PSA with yearly tests, I might have saved myself from my cancer getting any worse than it was, I would rather be proactive with choices than not knowing what is happening and then have worst choices later when I have an obvious physical sign.

Because of my elevated PSA over time, it triggered my Prostate Biopsy which only found 1 core out of 12 to be positive. In the end, I had more cancer than what it looked like and I am really glad I was involved in decisions instead of just rolling the dice with my life.

Knowledge is power !!!!

Curt

Taking my cue from ShoreGuy, I also emailed Dr. Brawley, as follows:

Dr. Brawley,
I am disappointed and angry that you have spoken out in favor of the USPSTF recommendation against routine prostate cancer screening.

I consider myself to be a living example of the need for routine screening. I'm presently 66 years old. My family doctor began including a PSA test as part of my annual physical when I turned 50. In recent years, the results went from the 2 range, to the 3 range, to the 4 range, and eventually to 6.2. My internist had been urging me to see a urologist for the last three years, but I, like many men, considered myself "bulletproof" and convinced myself that I simply had an enlarged prostate, as many men my age do. In May of 2010, I finally saw the urologist, who found a palpable tumor on the left lobe, and a subsequent biopsy found 6 cores positive for Gleason 7 prostate cancer (3+4). In August of 2010 I had a radical prostatectomy via DaVinci robot, healed quickly, regained continence in two months, but have lingering ED even now (hey, I'll soon be 67 years old!)

Just what do you think would have been my future had my internist not insisted on including the PSA test in my annual physicals? My cancer was judged to be organ contained with PNI, but the containment was pure luck....better outcome than I deserved for my bullheadedness in not seeing the urologist.

The biopsy was a mildly unpleasant procedure. I'd rate it a 1 on a pain scale of 1 to10. The DRE is something we men don't like, but it's really not a big deal, and I now have one every six months when I see the uro after my PSA tests. The surgery was much less painful than I expected it to be. I didn't even use any of the serious painkillers that were prescribed.

I'm troubled that you tend to characterize the routine PSA tests as mere moneymakers for the medical profession. Your anecdotal reference to one person who told you that does not impress me.

Demonizing the PSA test is simply ridiculous. It's a blood test, and though imperfect, it can and does send an alert that something is amiss in the prostate. Further testing can determine whether the problem is an infection, cancer, or something else, and if cancer is found the patient and his physician can decide what might be the appropriate course of action, whether Active Surveillance, surgery, or radiation.

The half dozen men in my acquaintance who have been treated for prostate cancer since my surgery have handled all this quite well. Two had surgery, several had external beam radiation. All are doing well. If they have ED or continence issues, they're dealing with those, and these are certainly not the end of the world. Many other cancer treatments produce SE's that are a whole lot more serious than the inability to achieve an erection or having to wear a pad.

I say, keep screening men. The more the better. But when the biopsy results come back Gleason 6, one core, low volume, don't rush the patient into surgery. That's where the changes, if any, to the current way of doing business should take place.

If we do away with PSA screening, I hope you can deal with the eventual parade of men into their doctor's offices with symptomatic, advanced prostate cancer. Their suffering will be on your hands, as well as on the hands of the USPSTF members.

We all know that a lot of men will welcome the news that they "don't need" to be screened for prostate cancer. Men already tend to find any excuse to avoid the digital rectal exam. The message many will take away from all this is that they should just stop worrying about prostate cancer and that they should worry more about those horrible, horrible treatments. How sad!

I feel we prostate cancer survivors have an obligation to become advocates regarding this issue. The message of the USPSTF will harm a lot of men, and that's a real shame.

He repllied within an hour, as follows:

 

Attached are the recommendations of 8 organizations regarding prostate cancer screening.


There is a problem with this test when none of the eight will just outright say men should be screened. I did not take part in any of the deliberations of any of the eight, including those of my own American Cancer Society.

If you read my writings carefully or listen to what I have said in the press, I advocate informed decision making. I am not against screening I am against duping men into thinking we have proof it saves lives. I am for informed decision making within the doctor patient relationship.

I keep hearing mortality is going down it proves screening saves lives. Truth be told, prostate cancer death rates have been declining in 21 countries over the last decade. 2 of those countries screen for prostate cancer. In the other 19, there is a lot less overtreatment. Keep in mind that the one thing that we do know is 60% of men with localized disease as found by PSA need no treatment. We need a test to figure out who each one is and watch him and not treat him.

PCa advocates have obstructed clinical research that might help us find such a test by relying so heavilly on PSA screening for which every study ever done has either failed to show it saves lives or showed that it saves very few lives.

You see I actually want to solve this problem and realize opinions like yours prevent it from being solved.

...........................................

WOW!  I never thought of myself as keeping this problem from being solved.  What a nice comment from the good doctor!

 

 

 

"You see I actually want to solve this problem and realize opinions like yours prevent it from being solved"

Wow, what a statement, I guess I am one of the problems also !!!!

Curt

i just emailed him about cases such as mine. 40 year old with no signs of anything from repeated DREs. I asked him if his European data covered cases such as mine.

I disagree with Brawley on a few points but I give him credit trying to respond to all. The truth be told his points are valid to a degree but I believe these guidelines accept the loss of certain men who can be and need diagnosis of the aggressive for of the disease for which we do not have adequate testing for other than the PSA test and DRE. In other words, I interpret his view to mean that to prevent the side effects of treatment for most men with prostate cancer that it is best to let a few men die of the disease.

It's hard for me to swallow that pill.

Tony

It's hard for me to swallow that pill. 

because his altruism sacrifices guys like you and me.

ed

 

Casey,
I have yet to see an acceptable form of PCa diagnosis that Brawley would support as appropriate. I have also yet to see a description, from Brawley, of a well informed prostate cancer patient that had a PSA test. He has never shown support for a newly diagnosed asymptomatic patient that I have ever seen.

It would be wrong of me to assume that he would be against my diagnosis, but clearly I believe that he would think it was totally inappropriate for me to have ever had a PSA test at this point in my life.

You don't have to agree with that, but he is an African American man who admits he has never, and will never have a PSA test despite his knowledge that he is in a high risk group. This sides in action with the USPSTF draft recommendation and not with an informed decision...at least in my thinking.

Tony

In any case, I wrote back and thanked him for the warm, caring, empathetic attitude displayed in his closing line to me, "You see I actually want to solve this problem and realize opinions like yours prevent it from being solved."  I'm sure he has a great bedside manner.

 

That's a good point Phenom.  Can you imagine the doctor/patient confab? 

Dr.:  I think you should have a PSA test.

Patient:  Why?

Dr.  Because you're of an age where prostate cancer could be an issue.

Patient.  Well, OK, if you think I should.

Dr.  But, I must warn you.  A needle will pierce your skin.  Blood will be removed from your body and examined by by an impartial third party.

Patient: Omigod!

Dr.  Wait.  It gets worse.  If your PSA is found to be elevated, a chain of dangerous, potentially life threatening series of events may be unleashed. A report of an elevated PSA may cause you to sink into a deep depression; it may cause thoughts of suicide; you may be shunned by your co-workers; your dog may no longer be your best friend.  The side effects are even worse than some of the cold remedies advertised on the 6 o'clock news!

Patient:  Oh, crap!

Dr.:  And the test may also lead me to request your permission to perform a digital rectal exam, a procedure worse than most of the tortures inflicted during the dreaded Spanish Inquisition.  My middle finger will probe your nether regions, looking for surface irregularities or certain textures regarding your prostate gland.  It's sort of like sodomy, really.

Patient:  I'm breaking into a sweat.

Dr.:  And if the DRE isn't bad enough, I may want to do a biopsy.  An even larger mechanical probe will be inserted into your bum, and as many as 12 pieces of your precious gland will be extracted microscopic examination.  The needle will pierce you bowel with each of the 12 extractions.  This is a horrible procedure, and some patients have been known to grimace or say "Ouch!"

Patient:  Is there more?

Dr.:  Yes, unfortunately there is.  If we find you have cancer, we may actually want to attempt to cure you and extend your life. We'll go after that prostate in full force.  We'll freeze it, radiate it, burn it, or rip it out using the impersonal, mechanical fingers of the DaVinci machine.  As you recover, you may be unableto control your urine, and sex as you currently know it may become a thing of the past.  There's even a chance you'll die on the operating table.

Now, shall I draw the blood for the PSA test?

The doctor turns to look at the patient, but all he sees is an empty chair as the door to the exam room swings closed behind the swiftly running patient. 

Yep, that PSA test is one dangerous, horrible procedure.  That's for sure!