My correct position on PSA Screening.

In another thread someone stated:
"probably have the same effect as not PSA testing young guys like Tony C ironically used to push on this forum a few years ago. we can now see how that worked out."

Since I know I was targeted with what I feel is a opinionated distortion (at best), there's some clarifications I think I'm entitled to make here. 1st I have never "pushed" to have no PSA screening in younger men at anytime here or anywhere. I was after all a 44yo that was diagnosed as advanced in 2006. I was not screened for prostate cancer per se because the "guideline" at the time stated to start testing men at age 50. 45 if African American or with family history. So I was outside all screening protocol at the time which I found frustrating. I vehemently sounded that alarm here at HW. Instead another medical condition was present that led to a diagnostic PSA test in my case that came back at 20ng/dl and began my journey.

My PSA viewpoint history:
Milestone 1: In 2009 the United States Preventive Services Task Force issued a Grade D recommendation to end all PSA screening in all men in the US regardless of age, family history, or race. Reviewing my posting here at the time will reveal that I was the first one to post about it and raise the flag of protest about it. This recommendation was based upon the review of two 2008 New England Journal of Medicine studies - the PLCO screening review in North America, and the ERSPC meta-analysis done in Europe. I was also the first to post those documents here as I was beginning to develop contacts in prostate cancer and Dr. Gerry Chodak (RIP) shared them with me before they were published. The USPSTF recommendation went through (Wilt, et al) and a lot of controversy followed. The recommendation was also silent on the use of a DRE.

Milestone 2: In 2010, the American Urological Associate (AUA) banded a panel together to review Wilt, et al, and to provide a counter research on screening. This was when I attended my first AUA conference in San Francisco and attended a presentation that found:
1. The USPSTF used a flawed study in the PLCO that determined there was no survival benefit to screening for prostate cancer
2. The USPSTF incorrectly used the data from the ERSPC document which stated that you would need to screen 1000 men and treat 43 in order to save a single life and that would also result in no benefit due to mortality caused by treatment and morbidities which were rampant at the time experienced by men treated with prostate cancer.
3. There was no oncology representation on the USPSTF panel and no experience treating prostate cancer was used.

Milestone 3: in 2013 the AUA panel issued a guideline on Early Detection of Prostate cancer. https://www.auanet.org/guidelines/prostate-cancer-early-detection-guideline The reason for the guideline was to refine issues in screening and to counter the USPSTF findings. Additionally, the AUA community as well as the ASTRO community, needed an expert panel to draft guidelines in help prevent legal and financial situations that were arising from the USPSTF. The methodology in creating this guideline reviewed over 800 studies and 115 were originally cited. (Later updated to 121). It was this document and my support of it that led to some here flipping out and creating a hostile environment for me here to resign as a moderator particularly with a few that absolutely were not willing to accept this and hold it against me leading to me leaving the site entirely for a while. In this guideline are 5 statements. The document is drafted to those that would be primary doing the screening as well as others in the PCa community including patients. The first 2 statements talk about screening younger men. They recommend against screening below age 40, and not routinely screening men between age 40 and 54. If you take the time to read the document they do not eliminate either as de facto rules. This was with the intention of providing guidelines using the available studies and science.

Milestone 4: The USPSTF, citing the AUA guideline, and updated data from the ERSPC, lifted the grade D halt to all screening. That was what I was hoping for but it did so conditionally. They only applied a Grade A to statement 3, and they did not adopt any of the other recommendations.

Milestone 5: in 2017, the AUA/ASCO/ASTRO/SUO reviewed this document again and reassembled a panel to tweak or modify it. This is the first time a patient representative was added to the panel. I was that patient representative and served on that review. In addition to reviewing the existing citations, we reviewed 77 additional screening studies. We found no data available to change the original guideline based on any science. So in 2018 we re-released the documents adding notations and 6 more citations. I spoke to and worked with the original panel raising concerns I heard here and other websites after the original release. Ball Carter brought up some points that we didn't get to hear in 2013. Namely:
1. Statement 1 was created because there was precisely no data on where and how PSA should be used in patients and that the primary care physicians that would be the likely do this screening, had very little information to use on PSA levels in a man in his 30's. The standard at the time for PSA screening was that if the PSA was below 4.0 everything was fine. We know very little still today about PSA kinetics in men in their 30's or even early 40's. But we know that using a hardline of 4.0 is absolutely mistaken in any men in the screening process regardless of age.
2. Statement 2 is the very first recommendation that allow any form of prostate cancer screening in men below the age of 45. I caught that right from the get go. I made that point to several deaf ears online.
3. The guideline clearly stated in 2013 and in the review that these are recommendations based upon cohort and not individuals. It clearly states that if a patient insists on PSA tests and the SDM requirements were met, they should be tested regardless of age or history.
4. We are still early in the study of molecular biomarkers but Carter felt then that as we can tie more high risk cases to genetic signatures in patients where a father or mother had prior cancer incidence that it could drive earlier testing in men. He also felt that new strategies will become available if and when we develop better screening biomarkers such as circulating tumor DNA (ctDNA) and biopsy (liquid biopsy).

Milestone 6: Published more recently are studies that outline that we are seeing an increase in high risk, advanced, or even mortality and some place the blame on changes in screening. More in depth look tells us there are several factors that have done this. An ASCO panel was assembled and found:
1. While more advanced cases are showing at presentation, overall survival was largely unchanged due to when a patient was screened.
2. The population is clearly heavier and has more co-morbidities than prior to 2005 screening guidelines when the controversy arose.

In 2005 the American Cancer Society's medical director, Dr. Otis Brawley, was adamantly against prostate cancer screening. Especially in African American men. I have met him at a plenary for SWOG and I asked him while he was on stage if he still held that position. To the gasps of the entire oncology group, he went on a rage about it citing racism and a medical community that was taking advantage and mistreatment of African Americans. Important note: Dr. Brawley is an African American. After the plenary I went up to Brawley and told him I disagree with him but I did admire his convictions. He stuck to his guns even though in my option he was contributing to what we find today in a drop in screening. he basically said "Good."

[edited here - per ASAdvocate] Last note: And many probably won't like this one. As an advocate that supports active surveillance, I fully acknowledge that after PSA screening changes, AS is the leading cause of increase in stage shifting in prostate cancer perhaps combined with the lack of science to improve screening. There are no perfect answers and no clear studies based upon prospective data on why this is. And it's not obvious either. To improve screening we need the following:
1. Education. Men need to understand that they can request screening regardless of age. But that guidelines are done to prevent abuse, misuse, and unnecessary treatment or diagnosis.
2. PSA alone is still a terrible screening tool. It's not prostate cancer specific and it leads to anxiety and even depression in patients who get "false positive" readings.
3. We need better biomarkers and radiographic imaging (these are coming).
4. We need less invasive tools for screening and biopsy.

I hope this explains more accurately than the above quote on my position on screening men. It hasn't changed since the BS I received for taking a position of agreement with a guideline that, to me, is still the best screening guideline based on science. As weak as they are at this point, I do expect molecular biomarkers to be included in the 2023 review and there may be changes to statements on younger men. Whether I serve on that panel or someone else, without better studies, improved biomarkers, or better education, I would not expect any changes.

Off my soap box.

Take care, get educated, discuss with your kids because if you want to help them, you have to.

(A couple changes made to mistyping)

Tony

Great thanks to you, Tony

NJ Fred

Tony thanks to you for clarifying.
I believe i came on the HW scene after you had already departed as a regular and frequent poster, and while i certainly dont wish that i was diagnosed at a younger age, I feel like i missed out on some level, not learning from you along the way.
Thanks for all you do in advocating for us, and for future PCa patients.

P.S. My son had his first PSA done at age 37 and has it checked annually since, he is now 40. Surprisingly, and thankfully, no pushback from his PCP when he first requested it.

Pratoman stated:
"P.S. My son had his first PSA done at age 37 and has it checked annually since, he is now 40. Surprisingly, and thankfully, no pushback from his PCP when he first requested it."

I told my sone the same thing. He is 34 now. It's not in the guideline for general practice, but it is not eliminated either. I have enough knowledge to help him along. One important note: He is my stepson but does not know the history of his fathers side. His grandfather, my wife's dad, did get PCa in his seventies. The important lesson here is that A PCP should not suggest testing, but should never deny a request either.

I remember when you joined as I was here at least until the end of 2014. Good to see you doing well.

Tony, I missed the original quote but nevertheless appreciate your clarification because I'm sure others must have seen it.

And, as always, thanks for your continuing advocacy on the part of patients with our disease. Having your educated opinion weighing in along side the docs is invaluable.

Jim

Good to hear from you again, Tony. You know, I don't remember if I ever argued any of these points with you, but just let me say I don't find anything to argue about now. Things occasionally got pretty contentious in those days.

I guess I was about 50 when my primary care doc started including a PSA test with my annual physical. The results were fine for a while but then crept up about a point each year until in about the six range, whereupon he basically ordered me to see a urologist, and the rest is history. That was ten years ago, and I owe him a lot for his careful treatment.
I have five male siblings. The youngest (now 62) and I have both been treated for prostate cancer. The rest seem fine.
Glad you're doing well.

Tony Crispino said...
...
To improve screening we need the following:
1. Education. Men need to understand that they can request screening regardless of age. But that guidelines are done to prevent abuse, misuse, and unnecessary treatment or diagnosis.
2. PSA alone is still a terrible screening tool. It's not prostate cancer specific and it leads to anxiety and even depression in patients who get "false positive" readings. ...

IMO the "great screening divide" stems from the misplaced stigma associated with PSA as a screening tool. The fact that PSA increases with PCa is a blessing. That it is non-specific for PCa is a drawback, but non-specificity is the rule for the majority of medical signs and symptoms. It's wonderful when, say, a skin rash is unique to a specific disease -- you have instant diagnosis! But this is the exception. Reducing screening and having to educate men that they can request a PSA for PCa screening not a logical way of correcting the misuse of PSA in the past (it reeks of having to request a library book from the locked "taboo" bookcase). It seems like the guidelines are for MDs and not patients -- is the patient who is abusing, misusing, and unnecessarily treating or is it doctors with MDs? Let's not reverse the role of patient and doctor. It appears that doctors need education here as much as patients. And if your PSA is rising for a reason other than PCa, it's not a bad thing to know that, check for other conditions, and keep an eye on your PSA, because, as I mentioned, this rise can mask PCa.

There are two viewpoints for public-health guidelines. On is the bird's-eye view of populations; the other is the egocentric viewpoint. For me the moral is: if I were you, I'd look out for you.

Djin

Lordy,
It's just so hard for me to imagine that increased screening doesn't increase survival and save lives.

It's also difficult for me to imagine that over-treatment can be reduced while using widespread screening. You just have to convince hysterical patients with a small amount of G6 that they don't need treatment. And you have to convince Uros that the same patients don't need surgery. Do you think that would ever happen? I suppose it's possible.

It's a friggen mess any way the problem is approached. In the meantime, I believe men are being diagnosed with advanced PCa who could have greatly benefited from earlier detection.

Bump

Ya ya gotta do what ya gotta do in this menagerie of hooligans and scalawags...and that’s just the tip of a huge iceberg in a polluted ocean...oh and so as not too add to a plethora of misinformation and distractive chit chat...this has zip zero nothing to with Tony...he is arguably the best moderator hw had sine I have been a
member...he actually had an unbiased knowledge of pca...the rest all very nice men just not very good wizard...no worries wings...I require no Sophie’s choice from anyone...I’m a stand alone guy with stand alone views. Oh and tanks for the bump to point your macula view...

Trends in clinical and oncological outcomes of robot‐assisted radical prostatectomy before and after the 2012 US Preventive Services Task Force recommendation against PSA screening: a decade of experience (2020, Full Text)

"Abstract

Objective
To assess the influence of the 2012 US Preventive Services Task Force (USPSTF) recommendation against prostate‐specific antigen (PSA)‐based screening on oncological and functional outcomes following robot‐assisted laparoscopic prostatectomy (RALP).

Materials and Methods
We retrospectively analysed patients who underwent RALP between 2008 and 2018 with a minimum of 12‐month follow‐up from a prospectively collected institutional review board‐approved database. The impact of the USPSTF recommendation against PSA screening on our surgical outcomes was assessed using a logistic regression model using two groups comprising patients treated before/after the USPSTF statement and indicating time trends for each successive year.

Results
The mean preoperative PSA increased from 6.0 to 7.4 ng/mL after the USPSTF recommendation. We detected statistically significant time‐trend changes after 2012, including an increase in the positive slope of Gleason ≥3 + 4 or ≥pT3 disease. We detected a fall in bilateral full nerve‐sparing and an increase in partial nerve‐sparing. The total positive surgical margin (PSM) rate increased after the USPSTF recommendation; however, PSM rates pertinent to each pathological stage did not change significantly after 2012. There was a significant negative trend change in the postoperative 12‐month continence and potency rates, indicating a breakpoint in functional outcomes after 2012. We detected a 1.7‐fold increase in 12‐month biochemical recurrence (BCR) rates. The 12‐month BCR, potency and continence rates were maintained in young (<55 years) patients with a Sexual Health Inventory for Men score >22 and low‐volume disease.

Conclusion
Since the USPSTF’s recommendation in 2012, we have seen a significant increase in the incidence of high‐risk disease that has forced us to modify our approach to the procedure and the grade of nerve‐sparing used, leading to a wider resection, in order to reduce PSMs. This has led to a decrease in postoperative functional recovery. Patients with favourable characteristics had good outcomes before and after the USPSTF’s recommendation, implying that the quality of surgery did not change over time."

[Emphasis mine]

Just one of a number of studies looking at the effect of the years of reduced PSA screening. As the 2016 NCCN definitions show, some G6 (3+3) and G7 (3+4) men actually have unfavorable intermediate disease because they have multiple risk criteria. I don't see why the identification of high-grade/high risk men has to be undermined for the sake of not wanting to identify the cohort of men who will be diagnosed as ideal for AS. This is a back-assward approach. The solution to "overdiagnosis" is AS, not screening avoidance.

Djin

halbert said...
...

Here's the thing: If we believe in patients becoming their own advocates, and taking responsibility for their treatments--and not just doing whatever the doctors say--then there will always be a significant number of patients who will respond to the word "cancer" with a gut reaction to immediately schedule treatment.

I do think we'll have excellent liquid biopsies and even better inaging that will give more confidence to the diagnosis of indolent vs significant PCa. But right now the distance between the two is small and based on the number of positive cores and percent cancer in each. This leaves a lot up to chance and hit or miss: one one day your uro's biopsy needle hits this tissue, on another day, that tissue. Or the needle goes through the thick part of some lesions vs. the thin parts. And perhaps just as important, we all know that finding only G6 lesions is not a guarantee that high-grade lesions are not there. Look at the large percentage of G6 biopsies that are upgraded after RP.

Bottom line: if -- despite a doc's advice that a patient's PCa can be safely monitored by AS -- the patient says no, zap it now, or cut it out now, that is their right. Who can guarantee that their cancer won't progess, that the short- and long-term results of treating in X years will be as good as treating now, or that their cancer really is indolent as the biopsy suggests? And then there is the reality that not all eligible men are cut out for AS -- a discussion point all its own.

Djin

I greatly appreciated this well-paced, thought-out, and well-written post.

Well, until I read this sentence:

" As an advocate that supports active surveillance, I fully acknowledge that AS is the leading cause of increase in mortality rates in prostate cancer."

No, that is NOT true for strict, formal AS programs such as at JH, MSCKCC, and UCSF. The death rates from prostate cancer in those groups is like one-tenth of one percent at fifteen years.

However, far too many men are trusting local uro's, who are too lax, or are "doing their own thing" and calling it AS, while not even bothering with doctors.They are taking dangerous risks.

My understanding of the current rise in mortality is due to missed PSA testing due to the USPSTF guidelines, not to AS programs.