Urology group stops recommending routine PSA test

Haha,
Guys read the guidelines. It does not eliminate screening. It tightens the restraints. I certainly met with many docs today here in SF and expressed my concerns with this recommendation but I arrived at the decision to agree with it all on my own.

I agree with the idea that there are too many ChrisR's, and many others, that regret their paths. I AM the 1 in 1000 as stated in the guidelines that was likely spared by a screening I didn't even authorize. I am even worse. At the time I was screened I had no family history though that changed after my diagnosis.

I am totally sympathetic to the "screen everyone in my family because I don't want them to deal with what I'm dealing with" approach. Please don't confuse this perspective as no longer being an advocate for guys like me or throwing in the towel. I assure you it's quite the opposite. I want the better test. The one that differentiates between aggressive and indolent prostate cancer. I don't view this as the need for less moneys for prostate cancer research, but a call for MORE moneys for prostate cancer research that will prevent the over treatment and over diagnosis of men afflicted.

Here's another point of view to chew on. The AUA is making this recommendation. These "uro docs" have been given a bad wrap as money hungry agenda driven professionals of raking in the dough by many here. And now they're idiots for this recommendation?

This is the tip of the iceberg of change in the medical profession as it pertains to our disease. ASCO meeting is next month and they will likely agree with these recommendations. I'll report on it. I'll be there. In addition, they will lay down more groundwork of the PCPT trials in preventive care.

I don't believe that the USPSTF was correct in throwing the baby out with the bathwater in their screen nobody recommendation. But I do think it woke up the medical industry. This is NOT what the AUA is recommending. Instead, what the AUA is recommending is a drastic change to the approach of identifying the uneducated patient, optioning the educated patient, and encouraging restraint in it's own specialty community to not over treat.

I agree 100%.

Thanks folks for your input. Keep it coming. I knew this will be a very important thread.

Tony

Tony,

I totally think the AUA and you threw in the towel.

The money will now just shift to the radiation / medical oncologists and the drug companies because of the increase number of patients whose cancer is well beyond the prostate.

until a better test is developed they should maintain the current PSA testing which has saved thousands of lives. Just look at the drop in mortality since the advent of PSA testing in America.

As for a test to differentiate between indolent and aggressive cancer, they'd better be able to fully recognize indolent cancer first. As Dr. Scardino said, it's impossible to be right 100% of the time about indolent cancer.

I feel terrible for ChrisR and am by his side 100%, but don't use him as an example. If you do, you should also use me and the countless more like me as an example.

Let me summarize in case anyone didn't read the guidelines, or they misunderstand them:

Category 1> Under 40. Do not screen. (patient can still order it)

Category 2> 40-54. OK to screen the high risk guys. If no signs or red flags wait until you are the next category. (patient can still do it)

Category 3> 55-69. Shared decision making regarding screening. Make sure the patient understands the risk/benefits ratio. (patient can still do it, regardless)

Category 4> Regarding repeat screening. Annual is unnecessary. Instead decision based screening every two years if the patient can be stratified into a high risk category. (patient can still do it)

Category 5> Over 70. Screen only men in good health. Men with less than 15 years life expectancy are not good candidates. (But the option is still theirs.)

My only swing here is high risk guys under 40 should not be screened yet. Annual screening is a waste of money and time. Population based screening is not good medical practice. And I agree that docs should not exert themselves to order screening without patient consent.

If this had been in place before the USPSTF recommendation, that panel would probably not have over did themselves. In fact, after the medical oncologists and the radiation oncologists jump on board, the USPSTF could back off their Grade D recommendation to end all screening.

That can be a win-win situation. I know it's hard to agree at all levels of these guidelines. But it's not a call at all to end screening. It's a call for evidence based screening.

I'm far from throwing in any towels. I'm hoping to lose the over treatment, and to lose the over diagnosis. (I know many don't agree that this exists but I know it does. It's not a particularly delightful thought that it exists but as in one example I've seen, doing a biopsy on a PSA screened otherwise asymptomatic 95 year old man is, I think, unethical)

Peace to all.

Tony

Post Edited (TC-LasVegas) : 5/4/2013 9:15:48 AM (GMT-6)

i'm not sure that covers someone like me. I was 40, not symptoms really, didn't order the test. My grandfather had PCa, my father didn't, but I don't think that ever came up at any of my annual visits.

So I could ave easily slipped into the next category which is 55 years old (assuming no symptoms developed which is entirely possible).

So what "could have" happed to my G7 if it went unchecked for 3,5,7 or up to 15 years?

TC-LasVegas said...
If your G7 went unchecked for any number of years after you turned 40 then these guidelines did not get followed. Your grandfather had it. You should have at least had the conversation.

Tony

But Tony, two things. How many people actually know the medical history of their grandparents? Realistically that leaves a ton of people in the dark. My G7 was asymptomatic and I was 40. It would go unchecked under those guidelines.

Are urologists going to start asking all 40 year old men if their grandparents had PCa?

Considering that most men die with PCa without knowing they even had it this too would seem to leave a vacuum.

What it comes down to is that these recommendations make it probable that a ot more people like me will slip through the cracks and find themselves with advanced PCa or PCa that has escaped the capsule in their 50s. Basically going back to the era of pre-screening when mortaility rate was a good 40% higher in America. Why? because it makes sense to avoid more situations like ChrisR at the cost of pushing fewer cases liek mine into advanced disease? I don't think so.

Post Edited (davidg) : 5/4/2013 9:30:27 AM (GMT-6)

Well sitting at this airport in SF waiting for a delayed flight...I have time to respond.

David first. How many men don't know their family history?

Probably the same number of men that don't know any of the other genetic ailments their father may have had. Or the same number of women that didn't know they were BRCA positive or negative.

Remember that if you don't know your family history then it might be prudent to do some soul searching on all possible ailments that are considered genetic. It might be prudent to have baseline screening as if you did have the high risk factors. I don't think the AUA would disagree with it. The definition in this recommendation specifically states men of "standard risk" don't need to be screened at your age. But that implies that you KNOW your risk factor to be in the safe category. It does not imply where to specifically place men that do not know their risk factors.

Keeping in mind that I was diagnosed before my father I still find these guidelines to be well thought out.

Tony

What a confusing issue this is.

I was diagnosed with prostate cancer at the age of 59 and my post-op pathlogy came back Gleason 9. My wife's father was diagnosed with metastatic prostate cancer in his late 60s and died of it a few years later. I have a 32 year old son. I've been worried that he might be at risk for PC because he has aggressive PC on both sides of his family. But now I find that, because my father-in-law and I were so old when we were diagnosed, he is probably fine, or at least too stupid to deal with proper management of a prostate cancer should he be diagnosed with one.

You might think that that would mean that I find the new policy statement absurd. But I don't... exactly. When you look at millions of men screened and hundreds of thousands of diagnoses and you try to balance thousands and thousands of lives saved against hundreds of thousands of lives badly and needlessly damaged, then, depending on how you weight things, you can come out with the new recommendations looking like a clear improvement.

But, if you pick any individual out of those cohorts and look at his particular situation then there always seems to be a better solution than the one proposed. In the case of my son, in a couple of years I plan to suggest that he get himself tested. If there is a better test than PSA and %fPSA available at that time then, of course, he should get that other test. At the same time as I suggest that he should get tested I will also try to educate him about the problem of over-reaction leading to over-treatment. He's a fairly steady guy. I think with a little education ahead of time he could make sensible decisions about the risks he is willing to take.

In the end, after looking at the problem at both levels I think I don't support the decision to limit screening. I have enough faith in individuals to think that in most cases with proper education they can handle information given to them. That way they get to decide what is more important for them -- a higher quality of life now vs risk later. That is not to say they won't regret their decision; but at least it will have been their decision to make, rather than having the decision made by some panel given the unenviable task of deciding who to throw under the bus, ChrisR or me.

"In the end, after looking at the problem at both levels I think I don't support the decision to limit screening. I have enough faith in individuals to think that in most cases with proper education they can handle information given to them. That way they get to decide what is more important for them -- a higher quality of life now vs risk later."

Bingo Peter. Well said!

Now I have to go to Texas for the first time in my life. BBQ which is not GFMPH in on tap tonight...

Jerry when you and I were diagnosed the guidelines were screen at 50. 45 if family history was present...

These are better guidelines.

Tony

Post Edited (TC-LasVegas) : 5/4/2013 11:04:48 AM (GMT-6)

Even being on this plane won't shut me up. It's a brand new plane and they opened up the internet for today!

To all,
A little PSA screening history here.

For about a decade+ the screening guidelines by the ACS, AUA, ASCO, and just about every organization until 2009 was to screen at 50. Screening high risk men at 45 didn't get added until 2000. It was in 2009 that the USPSTF draft was drawn up and it made quite a stir.

During that year, the comments flew everywhere. "Screen the population" was
rampant. I jumped on this reasoning using my own case as an example.
The ACS, with Dr. Brawley being the enemy to the patient base, has already made bold statements that he would never be screened and the ACS should not support screening. Eventually patient outcry led to the ACS changing the screening guidelines to include the "discussion before screening".

Organizations like ZERO are with the screen the population mentality, meaning every man no matter what, a mentality I see still in place with this weekends announcements by the AUA and the comments on their website. They added the "talk with your doc language", but still insist on annual screening for everyone.

PCF, has lightened their stance in recent years and I expect them to jump on board with the AUA.

ACSO has changed their guidelines to screen for a baseline at 40/35 with family history. But I suspect ASCO will also endorse these guidelines.

The NCCN is the same with ASCO and I suspect the same with them.

ASTRO membership is very rarely the screening agent. Radiation oncologist almost never screen or sponsor screening events.

The research NCI Co-ops basically stay out of the screening discussion.

UsTOO is with the basic guidelines of the AUA (before this weekend), and they have been very cautious at the corporate level, leaving the chapter to decide what they endorse.

The PCRI group is in line with PCF.

Other advocacies have been extreme and in favor of population based screening, and even other advocacies are more conservative.

Individual men diagnosed with this disease, including myself for many years, typically endorsed the screen everybody mentality.

These guidelines make sense but there are still men that won't buy into it because they feel they would have been left out. What I'm observing here is precisely that. I fully understand.

We've seen some additional tweaking going on at various times and I'm sure that some advocacies won't like the AUA announcement.

It took a lot to get the AUA to understand that men were being over treated. Even many RO's are still over treating men. Keep in mind that the AUA represents less than half of the urology community. Meaning there are many docs who will screen the population that come through their front doors. And many will still place the patient on their operating tables with one core positive G6 cancers in 70yo men.

Peace to all...

Tony

Post Edited (TC-LasVegas) : 5/4/2013 2:20:32 PM (GMT-6)

to davidg:

I understand, I think, but I feel you single out and over emphatize the plight of just younger men like yourself. PC sucks at any age. When I was dx. at age 56, my very experienced uro said I was one of his youngest ever PC patients. Us men in our 50's, our lives are just as important to our families as you men in your 40's. You may not mean it that way, but you sometimes come across that way in your posts.

I am one that feels that all human life is of equal value.

Just something to think about.

david in sc