New poll. This one is to see where we are today with screening in the patient community.

Tony I think giving men a baseline at 40 and then testing in future according to initial results is best.

Jerry,
The "Get a Baseline at 40" model is #2 and it's what the AUA, NCCN, ASCO, and the advocacies put into place after the USTSPF announced that they recommend against screening all men. If you look at all models, with the exception of screening all men annually at age 40, all models can miss prostate cancer in your and I as 40-45yo men. It is reasonable that both you and I could have had normal PSA's at age 40 and been told to come back at age 50. But that's how that model was designed. Only guys that had elevated PSA's at age 40, something that is very rare, would have been told to come back next year.

Tony

Tony,

My Psa was .7 at age 40. Got it checked just because...and rechecked just after I turned 44. Damage done already at a psa of only 4. I'm a bad example for screening.

I went with option two since I find it the least fecund of the array of crappy choices. As has been pointed out before, we need a better test and until we get one we are going to be faced with a series of lousy options for testing.

I understand and, to some extent admire, the methodological way the AUA went about coming up with their latest set of recommendations -- following the evidence wherever it went -- but in the end it strikes me that their recommendations are based on weak evidence and strong assumptions, notably the assumption that statistics drawn from past choices can effectively predict future behavior in an era with an increased awareness of the problems of over-diagnosis and over-treatment.

Tony,

As I understand it, the second choice is the "thrice in a lifetime" screening policy recently advocated by MSK and summarized below:
MSKCC PSA Screening Guidelines

men 45-49 screened:
if PSA<1 --> advised to repeat test in early 50s and at age 60
if PSA=1-3 --> advised to repeat test every 2-4 years
if PSA>3 --> discuss biopsy

men 50-59 screened:
if PSA<1 --> repeat test at age 60
if PSA=1-3 --> advised to repeat test every 2-4 years
if PSA>3 --> discuss biopsy

men 60-70 screened:
if PSA<1 --> end all screening
if PSA=1-3 --> advised to repeat test every 2-4 years
if PSA>3 --> discuss biopsy

men 71-75:
shared decision-making on whether to screen

men 76+: no screening

Their guidelines are based on a nested case-control analysis of the Malmö, Sweden cohort who gave blood samples at the start. For nerds like me who want to read their analysis, here are the links:

Strategy for detection of prostate cancer based on relation between prostate specific antigen at age 40-55 and long term risk of metastasis: case-control study
Prostate specific antigen concentration at age 60 and death or metastasis from prostate cancer: case-control study

The authors found that men in the 45-49 age group who had PSA in the top quartile had a .7% risk of developing a metastasis in 15 years, and a .3% risk of death from PC in that time. And those with PSAs in the highest 10% (>1.6), had a 1.6% risk of 15-yr metastasis and .7% risk of 15-yr death from PC (Tables 2 & 3). It is based on these levels that the authors recommend screening. There is no discussion of whether a later screening would have picked it up, and most importantly, whether such screening would have reduced their mortality: In the PIVOT trial, after 12 years of follow up, there was no significant difference in PC mortality whether they were surgically treated or observed after a median of ten years, and it did not differ by age group. The harms associated with screening this age group is also not discussed. Their strategy also carries the risks of many unnecessary biopsies.

Case control studies like this are considered weak evidence because of its retrospective nature. It represents a conjecture on their part of what might have happened had their strategy been followed. The only real way to know is with a randomized controlled prospective study. This was what was done in the ERSPC trial. Unfortunately that study did not include this younger age group; the men in the study were all 55-69. However, since ERSPC after 11 years has found no benefit to screening this older age group in which we know PC incidence and aggressiveness is higher, it would be hard to imagine that screening would benefit younger men. On the other hand, the harms are well known.

The AUA Guidelines are not the last word. As ERSPC data matures, it may very well turn out that there will be a more significant benefit to screening that may only emerge after 20 years or 30 years. After 14 years, there seems to be some divergence in PC mortality between those who were screened and those who weren't, and if the gap widens, the conclusions may be different. But no one has a crystal ball. Based on what is known right now, the AUA guidelines - recommending non-routinized testing and discussions with urologists prior to making the decision to test seems prudent. It represents a middle ground between the runaway routinized testing that has caused so much harm, and the USPSTF recommendation to never screen.

I vote: no vote. Don't like the choice of questions, seems to be rigged, like most surveys, to acquire a certain result.

Why David? You're opinion counts.

This poll is only highlighting the five choices of generally released screening guidelines by major organizations in the last four years. Which one do you think is the best one?

That's all I'm asking...

No tricks. No dishonest attempts. I stated that I think when I assessed that some challenged my conclusion that there are many that want every man tested every year. The belief this is best is founded on the very agreeable point that it will find more detectable cancer earlier. It will find as much prostate cancer as possible under all of the listed guidelines.

Tony

Tony,
You keep saying that some want to test every man every year. The reality is that as many as 50% of men above 50 (let alone 40) admit to ever having tested with PSA. This leaves a 50% pool of men at risk untested from the get go in spite of ANY guideline.

Even with this level of PSA testing, PCa mortality has been reduced. What is wrong with a baseline PSA test to further segregate those that might be at risk? Why was this not considered? If the intent is to do no harm first, then this new guideline is misguided. Preventing death from a disease is a primary requirement of any research.

I do not vote because an option to baseline PSA early and go from there is not an option when it should be a major benefit for men.

RalphV

ralfinaz said...
Tony,
You keep saying that some want to test every man every year. The reality is that as many as 50% of men above 50 (let alone 40) admit to ever having tested with PSA. This leaves a 50% pool of men at risk untested from the get go in spite of ANY guideline.

Even with this level of PSA testing, PCa mortality has been reduced. What is wrong with a baseline PSA test to further segregate those that might be at risk? Why was this not considered? If the intent is to do no harm first, then this new guideline is misguided. Preventing death from a disease is a primary requirement of any research.

I do not vote because an option to baseline PSA early and go from there is not an option when it should be a major benefit for men.

RalphV

thank you for posting that so clearly, Ralph.

I think we also have an issue with men knowing their family history. It's wrong to assume that all men will have this information. In fact 60%+ of people in specific groups grow up in single mothe households. How would they know?

These new guidelines are full of holes that create a huge risk for many men.

the poll displays incorrectly for me, btw.

Also find it weird that 6 of 12 people in this group approved of the USPSTF guidelines from last year.

Tony,
Option 2 is not what I am talking about. Believe it or not I am for the work of Vickers and Lilja. Baseline PSA (not included in option 2) to establish a rate of testing depending on results. Some men with low PSA might only need another PSA in several years. Others might require a closer range of tests. This would clearly be a more acceptable (to me) than all the options presented.

See how complex this issue is? You are an involved survivor an thought that my best option would be #2 because provided a test at age 40. The trick is to use the predictive values of PSA testing related to the level at the age of the person tested. Why ignore this when we have long term studies that help weed out some of the current problems with the non cancer specific PSA test.

RalphV

My answer isn't on there, I believe. I am still for testing at age 50, 40 for men with high risk factors, and based on that initial reading, re-test anywhere from every year to every five years thereafter.

david