Urology group stops recommending routine PSA test

John T said...
We are quick to attribute a drop in mortality entirely to psa testing. PC mortality had been dropping well before the advent of large scale psa testing. The incidence of PC also declined an average of 1.9% per year from 2000 to 2009 in the years of heavy psa testing when we would expect it to increase substantially. Mortality decreased by 3.5% annually during this same period. 54% of the mortality reduction is due to the reduction in the incidence rate of PC.
Unquestionably psa testing has had an effect on mortality, but it is nowhere in the range of 40%. The reduction in the rate of total incidences and treatments for advanced PC that extend lives are the most probable cause of the majority of the mortality reduction.

Actually JohnT, if you dig deeper into the SEER, you will see that the annual death rate of prostate cancer increased from 31.4/100,000 in 1975 to a peak of 39.34/100,000 in 1993 and then steadily decreased to 21.81 by 2010. Interestingly, 1993 was when PSA testing started to spread. Another statistic you might be interested is the 5 year survival for metastasized cases at detection today is only 28%, quite deadly in my opinion. This to me indicated all the advances in medical treatment is really not doing much to extend their survival even today.

In addition, 10 year cancer specific survival for those detected in 1975 was 53% as compare to > 98% for those detected today. This is a dramatic improvement by any definition. The only conclusion I can draw from all of that is that early detection (mostly because of PSA testing) saved lives. I cannot find any other explanation and if you can I like to hear it.

Regards,

Tony, you started this debate and now you walk away?

It's funny, you and the few others supporting this "new thinking" all benefited from the old thinking. Based on the new standards, you would have never been tested, think of how serious your diagnosis was, and a lot of other younger men at HW. So what you reject now, saved your very life.

Aren't the rest of men entitled to that as well? Seems a bit hypocritical to me.

As Jerry just stated, I will always be for that "one guy", because all of us here at one time, were "one guy".

Not to beat a broken drum, but work on the overtreatment part of the equation, leave the screening portion alone - give every man the chance and even advantage of knowing if they have PC or not. How they treat it is a different story, denying them the chance to know is not moral, it's plain wrong.

david in sc

PSA testing is not the problem, unnecessary biopsies is the issue.

I am "one guy" that hadn't had a PSA test in a few years but was given one during a routine physical.
Thank God it was done. The tumor was beginning it's climb out of the prostate when caught.
What if.............?

Bill from Florida

Normek said...
"Purg, I'll chime in on why I think the various committees and associations are focusing on testing to tackle the issue of over treatment, it's all about managing risk and liability. If a patient only get tested once symptons appear then the doctor is in the clear..."

Norm you need to reread the statements from the AUA. They are clearly suggesting guidelines on how to screen asymptomatic otherwise healthy men. Screening only takes place in men without symptoms. If you have symptoms the language about a PSA test changes to diagnostic testing as opposed to screening because your are trying to find the cause of the symptoms as opposed to to finding early prostate cancer.

So no the theory you present is incorrect based on the guidelines for screening in this thread are for asymptomatic men ONLY.

Tony

Post Edited (TC-LasVegas) : 5/6/2013 9:57:04 AM (GMT-6)

Tony suggested some clarifications which I generally accept. In no case does anything he says contradict anything I was trying to say and his clarifications are, in fact, just that. I have attempted to crow-bar them into my text. Tony's contributions (with a few minor changes) appear in blue below. Then I re-read the recommendations and added one more paragraph (in green).

Let me start with a couple of disclaimers here. First, I am not one of the one in a thousand whose life was saved by PSA screening. The first PSA test I remember having, and the one that set my feet on the road that eventually led to surgery, occurred when I was hospitalized with a prostate infection at the age of 54. That was when I acquired a urologist and his interest in my PSA was to make sure it went back down when the infection was cleared up. It did go down but not enough. So I was not picked up by random screening of healthy men. But I might have been... and I do sympathize with the one in a thousand.

I'll also mention, again, that I think the AUA's new guidelines are much too stingy with recommendations for testing. With proper education and support I think the average guy can make his own decisions if given the available information, although I do admit that the information provided by a PSA test leaves lots of room for improvement, as does most of the diagnostic information about prostate cancer.

These are recommendations and there are no restrictions. What they are offering is a reasonable (maybe not to all) set of guidelines for the field of GP professionals to consider when suggesting screening for prostate cancer. Right now that GP is looking at the USPSTF document to never screen and by far these guidelines are the lesser evil. If a patient walks into his GP's office, or attends a screening event and asks to be screened, he gets screened. These statements do not say you can't complete the patient request outside of these guidelines.

All that said, let's look at the forces that act on the AUA and why they made the compromise they did.

Statistics: The AUA, being an organization that operates at a national level does not directly face individual patients as their members do. They deal with statistical populations of patients separated by risk factors that determine their odds of having various sorts of diagnoses and of achieving various sorts of results. Some of those identified sub-populations, if you look at the statistics, would have been better off, if they weren't tested. For whatever reason, some populations tend to be over-treated, particularly youngish men with no racial or familial risk factors. Members of those populations will each have only a one in 1000 shot of having their lives saved by testing but a much, much higher probability that they will receive unneeded treatment and suffer life-damaging side effects, costing the health-care system money and being damaged in the process.

I'm not, necessarily, criticising the AUA for relying on statistical measures in compiling their guidelines. I'm only pointing out that statistical thinking leaves out details of individual situations and sometimes a set of guidelines makes a poor set of rules. The AUA is a membership of Urologists that treat patients. Like any committee they also have statisticians, advocates, and coordinators, but the committee Chairs are all urologists. Unfortunately when the USPSTF used epidemiology as the basis of their release, the appropriate response must use epidemiology to make it's counter point. Meaning, yes there are some statistics driving this recommendation, but the language is careful to tell anyone or any doctor that exceptions can be made.

But, after further reflection it does strike me as unfortunate that the AUA was backed into a corner where they had to rely so heavily on retrospective literature review. To a large extent this means that the acknowledged errors of the past are translated into immutable laws of nature. In the past -- that is, in much of the period from which the data were compiled -- men were poorly counseled prior to diagnosis and they tended to rush willy-nilly into treatments that may have been unnecessary and without an adequate understanding of the possible side-effects. In their recommendations surrounding "shared decision making" the AUA attempts to put in place some structure to ameliorate this problem, but the way they have structured their decision-making in coming up with their guidelines does not allow them to take any credit for that mitigation. They are forced to assume that future diagnoses will be as damaging as past ones, despite the new procedures for managing men's anxiety prior to screening, testing and possible diagnosis.

Societal Pressure: We are in the process in this country of looking at the way risk is spread for medical expenses and trying to find a way to spread the risk more widely, so that more people have access to help with medical care, while at the same time not bankrupting the system in the process. An inevitable part of this process is to look for wasted efforts that cost money and produce little value and trying to eliminate them. In this environment the AUA is under considerable pressure to show that it is doing something to address the problem of wasteful and damaging over-treatment of otherwise-healthy men with very-low risk prostate cancer. Other groups have called for an end to PSA screening altogether and the AUA is under considerable pressure to, at least, find a compromise position.

Ethics: Urologists are aware of the problem of over-treatment, and are aware that as a group they benefit financially from it. It presents them with an ethical dilemma. It is one think to agree in the abstract that some men are given needless biopsies or over-treated, and quite another thing to act on this knowledge when a frightened man and his wife are sitting in your office demanding categorical reassurances that the science does not support. Simply laying out the odds and letting the patient decide tends to lead to over treatment because most men know someone who has died of prostate cancer and they tend to be fearful.

In my case the decision to have surgery was made entirely on my own. I had talked to two surgeons. One surgeon (my second opinion) advised me to wait. My urologist (also a high-volume surgeon) told me it would be unethical for him to advise me one way or the other. I decided on surgery somewhat against the advice of my doctors and probably more out of fear than clear reasoning. It turned out to have been a lucky decision for which I can take no credit.

The ethics of the industry in this topic is a two way street. A "danged if you do and danged if you don't" dilemma is all over this topic. Urologists, medical oncologists, GP's, PCP's are all in on this wager but the odds of a satisfactory solution is a long shot and the best possible solution is unlikely to strike anyone as a perfect solution.

Defensive Medicine: In general it is more difficult to successfully sue a doctor for a needless test given than a statistically indefensible test not given that might have diagnosed a disease that subsequently causes trouble. Similarly, a doctor is less likely to be sued for documented and expected side effects of a needless operation than for recommending against a treatment that might have prevented progression of a statistically improbable disease.

The Man who Isn't There: Remember, what we are talking about here is testing for screening purposes. That screening is mostly done by other doctors. If you don't screen men from these populations who are least at risk from prostate cancer (and thus most at risk of over-treatment if you do screen them) then they will never show up at the urologist's office and they won't pose an ethical and legal dilemma for him. Add to that the suspicion that the men will (on average) probably be better off and it's hard to see the downside... From the point of view of the AUA.

Peter,
I like the post but there are some clarifications needed that might change your points a bit.

1> These are recommendations and there are no restrictions. What they are offering is a reasonable (maybe not to all) set of guidelines for the field of GP professionals to consider when suggesting screening for prostate cancer. Right now that GP is looking at the USPSTF document to never screen and by far these guidelines are the lesser evil. If a patient walks into his GP's office, or attends a screening event and asks to be screened, he gets screened. These statements do not say you can't complete the patient request outside of these guidelines.

2> The AUA is a membership of Urologists that treat patients. Like any committee they also have statisticians, advocates, and coordinators, but the committee Chairs are all urologists. Unfortunately when the USPSTF used epidemiology as the basis of their release, the appropriate response must use epidemiology to make it's counter point. Meaning, yes there are some statistics driving this recommendation, but the language is careful to tell anyone or any doctor that exceptions can be made.

I believe that the ethics of the industry in this topic is a two way street. A "dang if you do and dang if you don't" dilemma is all over this topic. I think the urologists, medical oncologists, GP's, PCP's are all in on this wager but the odds of a satisfactory solution is a long shot. What the AUA did was counter punch the USPSTF here. Does it go far enough into the intricacies and challenges of screening? Or is it the perfect suggestion? No. But does the USPSTF go far enough to save every man possible? Heck no!

I want to see that very depressing recommendation go away.

@normek. Litigious America strikes again. Your point well taken points out that practical medicine and litigation collide frequently in America. The AUA could have taken the simple legal out here and just ended screening after the USPSTF issued the no screening edict. How can you sue them if they follow the US government panels suggestion? Thank goodness they are fighting it.

Tony

Tony,

I edited most of your clarifications into my post. (above).

Ed,
At what point of your journey were your not tasked with the same decision making that weighed the pro's and con's of your potential decisions? This whole business is lined with decisions that all have good and evils.

Should I screen or not? Not screening can be an evil, but so can screening if one is not prepared to understand all the potential ramifications that go with it.

Do I treat or not treat? Both sides have an evil about them but it's not always the same answer looking at the black and white of it.

Surgery or radiation? Which had the lesser evil for you?

Do I do HT now or wait? Same story.

When do I stop therapy because it's just been too much? Not a decision I have had to make but same story? With some higher stakes involved.

As far as supporting these guidelines, it definitely seems among my friends here that if I just wanted to support the path of least resistance I messed that one up if you just read this thread.

But I know that sometimes you just have to stick to your guns. Sometimes that can be the lesser evil when it does not appear so obvious to the masses.

It is lovely, isn't it?

Tony

Post Edited (TC-LasVegas) : 5/6/2013 5:16:01 PM (GMT-6)

That's ok David.
I very highly respect your thoughts on this. And I take them to heart. I was on the "screen everybody kick" for much of my first five years here. I even took it to Capital Hill. I don't really view where I'm at with it today as a flip-flop. Instead these guidelines, in my opinion, are better then any we've had before. If you look at all of the screening guidelines from ASCO, ACS, PCF, AUA, etc. over the past five years I think everyone challenging me on this would agree. It's just not the supporting position of screening everyone that some would like to see.

But I do need to keep hearing all views. And I make the promie that I will listen.

Tony

Post Edited (TC-LasVegas) : 5/6/2013 5:22:48 PM (GMT-6)

ispark,

this is why screening shouldn't be discouraged or limited, every man has the right to know if he has PC or not. What he chooses to do with that diagnosis is a separate issue, and in Tony's discussions, he seems to refuse to separate the two issues. You have screening - good, you have treatment - debatable, as to when to treat and how to treat. If overtreatment is truly the problem - then focus on overtreatment.

Keeping men ignorant of having cancer makes no possible sense in my mind, and I speak this as a 4x cancer patient, each time with a dangerous cancer. On the first 3 bouts of the ultra rare porocarcinoma ,there is no doubt I would have been dead years ago, and wouldn't be here discussing prostate cancer.

And if this change of heart being put forth here is some kind of intellectual reckoning, that is wrong to in my opinion. This is about real men, with real lives, and real families. Not just a debating point, or some stat on a piece of paper. Doesn't anyone else care about the human aspect of this debate? I don't care who thinks they are smarter than the next, perhaps these embracing the new way, should spend some hospice time visiting those men that are still dying miserable painful prostate cancer deaths, perhaps that would re-focus their minds on what is really important here. Harsh? Perhaps, but a reality check might be in order.

david in sc

Tony -- what do you tell your friends in private when they ask why you didn't catch your PC early?  don't get tested?  I tell all my friends and anyone who will listen to insist upon an annual PSA test beginning at age 40.

the guy that took me up the bay bridge father-in-law was just diagnosed G7 with  a PSA of 6.  he is 70 years old and very healthy otherwise.  should he not have been tested?  his doctor wants to operate and I don't necessarily agree but he does need to be treated.

I am pro testing.  I will not agree with the side that helps create the ambivalence and apathy that almost killed me.

ed

 

good to have this discussion without someone posting that all/some of us are hysterical and PCa. The board has evolved.