AUA Comments On AAFP Position Recommending Against PCPs Doing DREs

I sent a copy of my original Healingwell Prostate Cancer Post to the AUA entitled "AAFP Recommends Against DREs For Prostate Cancer Screening" https://www.healingwell.com/community/default.aspx?f=35&m=3463417 and this is their reply:

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

The AUA last updated its guidelines in April 2013. They are:

1. The Panel recommends against PSA screening in men under age 40 years.
(Recommendation; Evidence Strength Grade C)
In this age group there is a low prevalence of clinically detectable prostate
cancer, no evidence demonstrating benefit of screening and likely the
same harms of screening as in other age groups.
2. The Panel does not recommend routine screening in men between ages 40 to
54 years at average risk. (Recommendation; Evidence Strength Grade C)
For men younger than age 55 years at higher risk (e.g. positive family
history or African American race), decisions regarding prostate cancer
screening should be individualized.
3. For men ages 55 to 69 years the Panel recognizes that the decision to undergo
PSA screening involves weighing the benefits of preventing prostate cancer
mortality in 1 man for every 1,000 men screened over a decade against the
known potential harms associated with screening and treatment. For this
reason, the Panel strongly recommends shared decision-making for men age
55 to 69 years that are considering PSA screening, and proceeding based on a
man’s values and preferences. (Standard; Evidence Strength Grade B)
The greatest benefit of screening appears to be in men ages 55 to 69
years.
4. To reduce the harms of screening, a routine screening interval of two years
or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce overdiagnosis and false positives. (Option; Evidence Strength Grade C)
Additionally, intervals for rescreening can be individualized by a baseline PSA level.
5. The Panel does not recommend routine PSA screening in men age 70+ years or any man with less than a 10 to 15 year life expectancy. (Recommendation; Evidence Strength Grade C)
Some men age 70+ years who are in excellent health may benefit from prostate cancer screening.

www.auanet.org/common/pdf/education/clinical-guidance/Prostate-Cancer-Detection.pdf

So they recommend shared decision making rather than an outright recommendation to screen. Sort of like the NCCN.

Now when it comes to the subject of Digital Rectal Exams, you may wish to read the study published in December 2012 in The Canadian Journal of Urology entitled "The digital rectal examination (DRE) remains important – outcomes from a contemporary cohort of men undergoing an initial 12-18 core prostate needle biopsy.” It is both recent and relevant.

Conclusion: Almost 50% of men in our cohort diagnosed with prostate cancer had an abnormal DRE. While only 14% of all patients with prostate cancer had an isolated DRE abnormality, 31% of these men had normal age specific PSA values. Such observations underscore the importance of the DRE for prostate cancer screening.

One of the lead authors, Dr Jay Raman at Penn State also responded to my email AAFP Recommends Against DREs For Prostate Cancer Screening with the following statement:

It is indeed a frustrating argument
DRE is simple.
Costs nothing
Can be done in the office setting
And can be done when checking for fecal occult blood (for colon cancers screening)
And....
10-20% of prostrate cancers are found on DRE alone with normal PSA
And....those found on DRE are more aggressive in general

Seems fairly straightforward to me

Hey Tony, glad you jumped in on Clanda's thread.

He and I live in the same town and we met last Friday at Starbucks for 2 hours discussing DRE's. I wondered if anyone over heard us

Luckily the guy next to us had headphones on. Clanda is very passionate about doctors continuing giving DRE's. if you look at his stats, he looked like he had nothing to worry about with such low PSA numbers. But he said his doctor "felt something" when he was given the exam and he had the biopsy to see if it was cancer.

I told him to maybe drop you an email and discuss it. I figured you would know something internally that may help him or support his cause.

Bill from Florida

OK I know why.

The article and recommendations by the AAFP and it was previously posted two years ago:

prostatecancerinfolink.net/2013/11/11/poor-guidance-from-the-aafp-badly-interpreted-by-the-media/

Mike adds that a reporter was totally brain dead in his reporting.

No Pulitzer for him...

I'll be having my annual physical with my PCP in a month or so. Even tho I am no prostate-less and no longer require a DRE (or do I?), I'll ask him about this. I wonder what he'll say.