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

clocknut said...
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!

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Great job clocknut !!!! is this what it all really boils down to ?? What is everyone thinking [img]/community/emoticons/shakehead.gif[/img] !!!!

Curt

**Post edited to fix screen display issue.

Post Edited By Moderator (Steve n Dallas) : 5/24/2012 1:38:59 AM (GMT-6)

Hah! But not so funny, really. Someone should ask Dr. Brawley what such a discussion about a PSA test WOULD consist of?

232,000 men a year are diagnosed with prostate cancer....I am willing to bet a PSA test played an important part in discovering these cancers. Brawley claims 60% of these men need no treatment, or for 139,000 the knowledge of their cancer is unimportant as the cancer is not a medical problem..But what about the other 92,000 men who will require treatment if they are to avoid death caused by prostate cancer? Without routine PSA screening, their chances of survival are greatly diminished as their aggressive cancers would not be discovered until the prognosis was grim...

The problem with statistics, whoever is paying for the statistical study, they are certain to get the results they want..

Who would benefit the most if routine PSA testing was no longer performed? Medicare and the big companies who provide medical insurance, that's who...Dead people can't generate medical bills...

Sorry, I may be biased. Where is the harm in my PSA testing that I did not even know was being done every six months as part of my cholesterol screening. After a week long bike trip across Iowa, the following month during my regular screening it includes a spike in PSA. GP says may be a result of the bike ride so let's wait 3 months and retest. I'm fatigued, lower back stiffness and perineum is sore ( maybe biking related, maybe just getting old). Three months later not much movement in PSA. We decide to wait another 3 months without much change. I get referred to Uro where I'm put on Cipro for several weeks and not much PSA movement. A month later biopsy is scheduled and 9 of 12 cores positive at GS6. With my Uro, upon informed decision making, I make the personal choice for Da Vinci surgery. Almost one year from PSA spike, I have the surgery. The path report is downgraded to GS7 (4 + 3) with 20% TI. No incontinence issues, very minor ED, no lower back stiffness, no perineul soreness and an energy level like in my 20's.

Where is all that harm with that PSA test? I would do it all over again, however, I wouldn't have known without the PSA screen. I view my GP as a hero for the PSA screening that I really did not take the time to realize it was being done.

As far as I'm concerned the USPTF lost their credibility a few years ago with their mammography debacle.

Whoa...Im_Patient...way out of line, IMHO. What the heck is wrong with you to wish cancer on someone?

Tudpock (Jim)

This thread has a lot of "uninformed" speculation about what the ACS's "informed" decision-making is all about. This just demonstrate how important it is to educate men about prostate cancer...even men who have already been treated, rushed or perhaps not, may need to continue their education...


It's not that hard to find out what ACS means by "informed" decision-making, but apparently nobody took a minute to look before replying. The ACS and other organizations have materials available free online. Thankfully, your ACS fundraising dollars are helping to educate men about PC, screening and treatments.



Thank you for contributing to this common-sense ACS video to help educate men:


http://www.youtube.com/watch?v=Vg9iBOzIo38




And thank you for contributing to ACS for the creation of this video for clinicians about "informed decision-making":


http://www.youtube.com/watch?v=_ZIz4Fxqio8&NR=1&feature=endscreen




Here's a link to several non-ACS brochures which have been produced about "informed decision-making" about PSA screening...all free online (no need to speculate about what "informed decision-making" means). Essentially all of the professional organizations think "informed decision-making" about PSA testing is the smart decision:


http://www.sph.emory.edu/eprc/prostate/informed.html

Post Edited (Casey59) : 5/24/2012 4:40:36 AM (GMT-6)

he wrote back to me. He was respectful and provided numerous links. In response to my direct question about young guys like me he said that none of the organizations he supports recommend screening in men my age. So he's relying on old data because more and more young guys are getting it. He said he wasn't against consenting well informed PSA testing, but that he was against mass screenings at churches and malls. I don't go to churches or malls.

i really don't think urologists, surgeons, radiologists are out to get us and dupe us. If Brawley is correct even AS practitioners would be coning us as they are charging dearly for surveillance services that aren't needed theoretically.

I guess I was lucky in that my urologist explained all my options, including AS and explained the nature of my cancer to me. After that it's about the choices we and our doctors make. But how can we make those without knowing we have cancer?

Brawley is against mass screenings but for agreed upon and discussed testing. Why not simply work on that instead of discrediting PSA testing altogether? Probably because there is a financial motive behind it.

i've had several additional email exchanges with Dr. Brawley and they've been cordial and informative.  He's obviously very concerned with men who end up being harmed, rather than helped, by the treatments which follow the PSA test, and he doesn't seem convinced that the majority of men are actually being helped by these procedures.

I still feel, though, that it's better to test than to not test.  I can't think of another medical condition where the medical community thinks it's preferable to remain ignorant of a condition. 

How to best treat the condition may be problematic.  Maybe it doesn't need to be treated.    But it's as if we're being told, "It's better that you remain in the dark about this.  That way, if you're harmed by it, at least it won't be our doing." 

 

clocknut said... He's obviously very concerned with men who end up being harmed, rather than helped, by the treatments which follow the PSA test, and he doesn't seem convinced that the majority of men are actually being helped by these procedures.    clocknut, As a public health professional, I think that he should be concerned about the large number of men who end up being harmed through overtreatment for PC balanced with the small number of men who are helped.   The screening process needs to shift away from mass screening to find prostate cancer, and shift to a more focused, informed effort to separate-out those with high-grade prostate cancer…this approach helps BOTH groups of men (the large harmed group, and the small helped group).   So what exactly has Dr Brawley advocated?   These points which address BOTH the large number of men harmed and the small number of men helped: ·          Promoting “informed decision-making” between doctors and patients (and making facilitation materials available) before screening ( not instead of screening) ·          Discouraging un-informed mass screening (revenue generating for hospitals by treating low-risk men) ·          Disseminating the scientific data which shows the great number of harms versus the small number of benefits in the current modus operandi …which helps to get the word “out” so that educated patient advocates (like us) can help to properly steer newcomers away from rushing into unnecessary treatment; it is clear that—intentional or not—large numbers of men are deceived into thinking the net outcomes of PC treatments (particularly when one includes the cavalcade of medical interventions which follow) are better than they actually are ·          Advocating for a better test to better distinguish between prostate tumors that need to come out and those better left alone, while expressing frustration with those who are distracted by seeking the super-hypersensitive son of, son of PSA (Dr Catalona, are you listening?)   Which of these points made by Dr Brawley do you think he should slow down on, stop, or reverse? Dr Brawley's own words (below) should help stop HW posters from improperly attributing the wrong messages to him; read this, or re-read the email responses he has sent before putting words in his mouth:  http://www.annals.org/content/early/2012/05/21/0003-4819-157-2-201207170-00460.full   Post Edited (Casey59) : 5/24/2012 8:32:32 AM (GMT-6)

All the studies that are done and information we receive in regards to screening for PSA is based on "does it saves lives or not". For me there is more to PC that living or dying, there's the issue of localized or advanced PC. Are there any studies out there looking on how PSA screening has affected the number of diagnosed advance prostate cancer cases, I think that if there is one thing that everyone can agree on is if the patient is to have the best possible odds at beating PC and to have all treatment options available to them, it is better to be diagnosed while the cancer is still confined to the prostate. The science and the medical world will only get better and better in treating and extending the life of men with advance prostate cancer, does this mean that it's ok to stop the psa screening and only treat men once symptoms appear? That way I look at it is that those opposed to screening are saying " look we are getting pretty good at saving the lives of men with prostate cancer so who cares if you have advanced PC, you not going to die from it right away".

In my uncle (my dad's older brother), I saw a strong, healthy and fit man beat down to nothing by 16 years of radiation, hormone and chemo therapy, when a simple yearly test could have detected the cancer before it escaped the prostate (only visited doctor when symptoms appeared). My dad and uncle #2, seeing what was happening to their brother both started yearly PSA screening, a few years down the road both have been diagnosed for local PC, chose different treatment options and both are now doing great. My dad did deal with some ED issues but says that it's nothing compared to what is older brother went thru, so I personally don't 100% buy into the statement that QOL complications from treatment outweigh the benefits of treatment.

At age 44 I had 1 of 12 cores positive, with a gleason 6. Am I considered overtreated, maybe? Instead of being classified as overtreated was I just treated early because of PSA screening, most likely. Because of PSA screening have I greatly reduced the odds of developing advanced PC, most definite. My final pathology indicated cancer all along the front edge and top of my prostate, 35% of my prostate was cancerous.

         

clocknut, you're welcome.  Informed discussion, and informed decisions, are both important. 

clocknut said...

What a weird situation the urological community has worked itself into!

  

Agree.  They need to continue to "feed the beast."  But it's not just urologists.  Proton beam therapy (radiation oncologists) is another case in point.  PBT was basically a solution looking for a problem to solve...and it found prostate cancer.  The infrequent number of brain cancers and other similar cases for which it offers superior results simply could not justify the costs of the equipment, but the boom created by mass PC screening is helping to fill the void.  (Just ask their marketing departments)

added later after re-reading your last reply to me, clocknut, on one of the themes of the materials:

 

I agree that it is, and should be, a key theme of the "informed decision-making" materials that men should realize that if they have prostate cancer it does NOT mean that they need to treat it aggressively.  That's precisely the point on overtreatment.  Whether they know it right now or not, 65% of men your age (based on autoposy studies) have a form of what we now call "prostate cancer."  In fact, only a small percentage know that they have it.  It'll never cause a problem for the vast majority, but for those who stumble into (especially those who are "un-informed") PSA test/biopsy which indicates that they have PC, they more often than not will make a decision based on the "cancer hysteria" that has been conditioned into them that they "want it out now," when in many cases they probably don't need to do that.

 

"Americans have been taught for decades to fear all cancer and that the best way to deal with cancer is to find it early and treat it aggressively. As a result, many have a blind faith in early detection of cancer and subsequent aggressive medical intervention whenever cancer is found. There is little appreciation of the harms that screening and medical interventions can cause."

 

 

Post Edited (Casey59) : 5/24/2012 10:02:13 AM (GMT-6)

Phenom,

Forgive me if I seem sarcastic or impatient, but it seemed to me that these numbers have been posted and reported a thousand times.

Here's a good graphic to show you:  LINK    This visual aid helps to give a feel for the number needed to treat to save one life.