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AAFP Recommends Against DREs For Prostate Cancer Screening

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Posted 7/31/2015 3:50 AM (GMT 0)

clanda said...
I'm a bit surprised that I did not find much support here for Digital Rectal Exams. Do most of you really feel that their routine use should be curtailed? While they're not fun, if the Dr picks up on an abnormality such as a nodule, wouldn't you want to know about it? There would be a fairly high percentage of them that are Pca, with or without a corresponding PSA test.

It's unlikely that a DRE will detect early stage PC. By the time it can detect PC, it's likely there are other symptoms.

Also, not all doctors really know how to do a DRE correctly. A DRE is useful to help a doctor screen for other things related to the prostate and rectum. As a test for PC, it is only a small part of screening.

In my case, the DRE never showed any problems (except for one doc who said my prostate was 'squishy' whatever that might mean). My PSA was tested because of a family history of cancer, including PC. After a short conversation the doctor and I decide it was prudent to get a baseline PSA after my mother died of pancreatic cancer. I also have a history of colon polyps as well as a concern over skin cancer. With all this my PCP recommended not only a PSA test but also a colonoscopy.

If my PCP had relied only on a DRE, she wouldn't have discovered my PC.

The problem with the recommendation is this sentence: "Physicians should not offer or order PSA screening unless they are prepared to engage in shared decision making that enables an informed choice by patients."

Too many doctors aren't willing do do the education needed for effective shared decision making. Sadly most people only read the first part of the sentence, "...should not offer..." and never get to the "... informed choice by patients."

Back to the DRE, I don't think they should be curtailed, but I do think they should be performed by doctors who know how to do them, know what they are looking for and educate their patients into reasons for the DRE.

I felt my PCP was following the recommendation by engaging in educating me on the kinds of cancers I was at risk for and what the risk/benefits of the various screen methods were. Once I knew all that it was simple for me to said, "I'll do the PSA and drop my pants." In addition to the basic clinical testing she also discussed what symptoms to watch for, how to improve my diet to reduce risk and had me start taking Vit-D since I tested on the low side for that.

If your doctor won't go that far to help you be healthy, you need a new doctor.

Andrew
Posted 7/31/2015 4:12 AM (GMT 0)
In the protocol I use as part of my Active Surveillance of my PCa, I take PSA tests every six months and a 3T mp-MRI every year. My urologist and I have skipped the DRE since it is the least sensitive of the tests and it is very unlikely to find cancer not indicated either by the PSA or MRI.

Interestingly, the last DRE I underwent was administered by the surgeon who I consulted who tried to convince me to treat my cancer surgically. When I resisted, he administered the DRE and found my prostate hard on one side. He sent me off to get an MRI to look for EPE; it was negative. In the meantime, I found out in a Mayo clinic factsheet that previous surgery such as a TURP can compromise the architecture of the prostate and affect the DRE.
Posted 7/31/2015 2:00 PM (GMT 0)
InTheShop,

You stated above "It's unlikely that a DRE will detect early stage PC. By the time it can detect PC, it's likely there are other symptoms."

Have you read my signature? Did you not notice that I had a PSA of 1.6, a nodule discovered by DRE and a path report of Gleason 7 after RALP? I am not alone in having an abnormal DRE raise the red flag that lead to a biopsy and diagnosis of Pca absent an elevated or high velocity PSA history.

In your case you state "If my PCP had relied only on a DRE, she wouldn't have discovered my PC." That was YOUR experience.

DREs are extremely subjective. However, if you have an abnormal one, you'd better have a biopsy performed because whether the odds are 1 in 5, 1 in 4 or 50-50 you have a reasonable chance of being diagnosed with Pca.
Posted 7/31/2015 2:34 PM (GMT 0)
clanda - and? isn't that why a full spectrum of screen methods should be used? This isn't one size fits all. What works for you won't always work for me. DRE found yours, good, didn't find mine, bad.
Isn't that the point?

Prescribing one simple screening method for everyone isn't going to catch all PCs. Education plus informed and shared decision making between doctor and patient will.

Andrew
Posted 7/31/2015 2:43 PM (GMT 0)
I find the recommendation against PSA testing rather unnerving. My father in law was treated for and after 20 years eventually died from PC. My husband had PSA tests for 3+ years and after AS and two biopsies was also diagnosed with PC. His first biopsy had no cancerous cores, two years later the second one had 9/12 cancerous. PSA rises led to our decision to treat with RALP. His tumor was on the abdominal side of the prostate and as such was not palpable by DRE. So based on this recommendation against PSA testing! I am now frightened that my FOUR sons will not receive appropriate testing and care.
Posted 7/31/2015 2:43 PM (GMT 0)
InTheShop,

Of course a full spectrum of screening methods should be used. However, if primary care practitioners choose to no longer recommend PSA testing for prostate cancer screening, I do not want to see them simultaneously choose to no longer do digital rectal exams as well. That is my only point!
Posted 7/31/2015 3:07 PM (GMT 0)
my point is, if your PCP has mindlessly accepted the recommendation, they've likely abandoned both DRE and PSA.

If your doc is like that, you need a new doctor.

Andrew
Posted 7/31/2015 7:35 PM (GMT 0)

InTheShop said...
my point is, if your PCP has mindlessly accepted the recommendation, they've likely abandoned both DRE and PSA.

If your doc is like that, you need a new doctor.

Andrew





Hopefully, you really meant something like this:

Keeping in mind that the recommendation is this: "Physicians should not offer or order PSA screening unless they are prepared to engage in shared decision making that enables an informed choice by patients."

If your doctor is screening patients without first having a conversation which informs patients about PC, (s)he is not following the ethical recommendations of his/her professional association...get a new, ethical doctor.
Posted 8/1/2015 4:04 AM (GMT 0)
And the controversy continues.

The AAFP website states that they represent 115,000 family practice physicians. But I am certain that 115,000 members do not agree with this statement. There are several committees in these organizations and they can be weighted in the selection process. The political process is always in play when you see this stuff.

I think it's important for us survivors to let our family practice docs know that we do not agree with this. That it is a matter for the oncology practitioners to define. The USPSTF did not have a prostate cancer specialist on their committee and neither do they.
Posted 8/1/2015 10:44 AM (GMT 0)
The tragedy is that there are many, many men who see the headlines and don't go further, and dismiss the whole mess as pointless. What these well publicized, headline grabbing reports do, in fact, is create more situations where men wait until they have frank symptoms, with mets, and they have last ditch treatments and die horribly and too soon.

The cynic in me wants to quote Dickens. "Perhaps they should just die and decrease the surplus population"
Posted 8/1/2015 3:46 PM (GMT 0)
I look around this forum and I see a whole lot of men whose lives were saved by PSA screening and/or DRE. So to me, the Maxro just doesn't mean very much.
John T, I totally understand your point, and it's a good one, yes we are biased. But the reality is, we have reason to be.
I'm much less interested in cost benefit analysis, than I a, in saved lives, and the lives of our sons.

I think DRE and PSA screening are not so much the issue, as how the results are utilized. Physicians need better training in using these tools and just as important educating and empowering their patients as to what next steps to take, or not take.

The idea of no longer using DRE especially sounds ridiculous to me. There is virtually no risk to the procedure, and no real cost. Why stop using it as a tool?
This whole idea of placing minimal value on screening tools that clearly saves lives is stomach churning to me. No different than the arguments against mammograms.
Again, I care more about the micro. How many lives are saved? Count the ones here, alone,
Posted 8/1/2015 4:54 PM (GMT 0)
Pratoman,

I like the way the way you think! And you also chose Dr Tewari to do your RALP. Like minds tend to think alike. I appreciate your support on this issue as should all of us "micros" still walking around who have benefited from these diagnostic tools.

Be well!
Posted 8/1/2015 10:01 PM (GMT 0)
And as I've said many times Clanda, Tewari was the best decision for ME, that i've ever made.
Posted 8/2/2015 12:11 PM (GMT 0)
"Keeping in mind that the recommendation is this: "Physicians should not offer or order PSA screening unless they are prepared to engage in shared decision making that enables an informed choice by patients.""

This is the key to it all. In these days of 15 minute office visits (mandated by the insurers), these conversations can't happen, because (a) it screws up the schedule and (b) the insurers won't pay for it.

Sigh.

PS: Got home from Maine last night, back to the grind on Monday. Had a wonderful evening with WG and Mrs. WG in Rochester on the way home. Looking forward to the end of September.
Posted 8/2/2015 5:13 PM (GMT 0)
I'm heartened to see the discussion re the pros and cons of PSA testing and DRE's. This to me is a conversation that should grow and spread well outside of HW.

Data from the National Oncology Data Alliance recently presented indicates that men with newly diagnosed PCa are presenting with higher PSA levels since 2011 and that a higher number of high risk PCa's were diagnosed between 2011-2013. Is this because of the USPSTF's recommendation against PSA testing as well as the other major organizations attitudes re PSA testing and DRE's? That's up for discussion and it really needs to be a vigorous public discussion. We're losing 28,000 of us who are fighting this disease annually, do we want that number to go up?

The AUA and other recommending organizations talk about having conversations with your Dr. and and making informed decisions about PSA tests. I remember the conversation I had with my GP before I had the PSA test that lead to my diagnosis of PCa. (The PSA test doesn't tell you you have PCa, it's level and velocity are information to be used to determine the need for further testing) It consisted of "you can have one if you want one'" that was it! The large medical group he works for I'm sure was/is the driving force for non-committal attitude. AND behind that, I can't help but believe, are the insurance companies.

There are no cut and dried answers in the PSA/DRE debates, but the debates need to be reopened in the public domain. The average patient facing the decision re PSA/DRE needs to be able to have a decent conversation with his GP and be able to fully evaluate the pros and cons of PSA/DRE's. Side effects from diagnosis and treatment (I have all of them) are certainly an issue, but dealing with and dying from metastatic PCa is not a good option.
Posted 8/2/2015 5:41 PM (GMT 0)
willda109,

Thank you for adding an additional dimension to this discussion. I had not read this before. Are we, as men, supposed to turn back the clock to the "good old days" when we would generally only present ourselves for prostate cancer screening (THE DRE) after we were showing symptoms and perhaps getting to the party a bit too late for any meaningful treatment options? My dad lasted one year in 1978 after presenting himself only because he was totally unable to pee!

Thank you again for the info.
Posted 8/2/2015 9:52 PM (GMT 0)
>>These people who advocate stopping routine screening for PC are willing to throw the 35%-40% of us who had our aggressive PC detected by a PSA screening under the bus..<<

in a nutshell, YES!!!

and some of these guys will try to pass themselves off as your friend.

ed
Posted 8/2/2015 11:37 PM (GMT 0)
There were 176 comments to the recent editorial in the NY Times, and most were against screening. You guys are going to have to put up a lot more than righteous indignation based on your own experience to sway the masses. The necessary steps are 1) to fine tune screening and treatment protocols to optimize benefits over harms and 2) conduct studies to prove net benefits.

http://www.nytimes.com/2015/07/06/opinion/bring-back-prostate-screening.html
Posted 8/3/2015 12:28 AM (GMT 0)
Testing 123,

Wow! Everyone on this forum should read that New York Times editorial AND the comments. I am wondering if the type of person who responded and wrote comments that were against screening is just trying to rationalize how little control he wants to believe he has over over his own life and simply wants to believe that bad things happen and that he has no way to deal with them...so he's not responsible. Don't ask...Don't tell..Maybe die! How sad.
Posted 8/3/2015 5:32 PM (GMT 0)
AUA Comments On AAFP Position Recommending Against PCPs Doing DREs:

I hope this email finds you well. I am writing today in my official role as the Chair of Public Policy and Practice Support for the American Urological Association. Our communications staff received the email you sent to them (which included your email to AAFP and their response) and forwarded it to me. I want to complement you on your well-thought out comments and let you know that the American Urological Association agrees with you entirely. On a personal note, I completely agree with you and frankly think you laid out the argument better than I ever could have.

The AAFP response is typical and unfortunate. They made up their mind on prostate cancer screening years ago- long BEFORE the release of PLCO. They neglect to even mention and effectively ignore the ERSPC trial which was just as large as PLCO and which showed that in European men, prostate cancer screening demonstrated a survival advantage. As an author of the evidence-based AUA guidelines on prostate cancer screening, I know that our panel acknowledged that prostate cancer screening is imperfect and has resulted in over diagnosis and over treatment (as you mention in your email). Simply put, the data re equivocal and there are both benefits and risks to screening. Therefore, each patient should be able to make his own personal decision as to whether or not he wishes to be screened. To this end, we recommend shared decision making around prostate cancer screening for men age 55-70 at average risk for prostate cancer in our guidelines.

We have tried for years to have a thoughtful and productive intercourse with USPTF and AAFP around these issues in hopes of reaching some sort of consensus of the topic that would really help guide patients. Unfortunately, neither organization is interested in including the AUA in their deliberations concerning prostate cancer screening recommendations. We would argue that we are the true content experts on the subject while they argue that we are biased. Sadly, I don't see this situation changing anytime soon. To this end, there is little we can do about the AAFP's choosing wisely recommendations. The initiative is run by the American Board of Internal Medicine Foundation, which allows every specialty to provide its own recommendations without input from others. We protested AAFP's earlier recommendation around prostate cancer screening to the ABIM foundation. Despite our efforts, ABIM Foundation allowed the AAFP recommendation to remain. Our recent Choosing Wisely recommendation around prostate cancer screening is as follows and is clearly at odds with the AAFP. Unfortunately, this is the best we can do where choosing wisely is concerned.
June 11, 2015
Offer PSA screening for detecting prostate cancer only after engaging in shared decision making.

Shared decision making (between health care provider and patient and, in some cases, family members) is an excellent strategy for making health care decisions when there is more than one medically reasonable option. Since both screening and not screening may be reasonable options, depending on the particular situation, shared decision making is recommended.

We firmly believe that shared decision making is the best way to approach prostate cancer screening and is supported by the evidence. We continue to push back against opinion-based recommendations, like those from AAFP and USPTF on numerous fronts. We appreciate the comments of prostate cancer survivors, like yourself, who represent those most affected by these types of recommendations.

Please feel free to contact the AUA or me personally if we can be of additional assistance.

David F. Penson, MD, MPH
Hamilton and Howd Chair in Urologic Oncology
Professor and Chair, Department of Urologic Surgery
Director, Center for Surgical Quality and Outcomes Research
Vanderbilt University Medical Center
A-1302 Medical Center North
Nashville, TN 37232-2765
(615) 343-0234
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