Finally a more prudent statement… (Round Two... *ding*)

I'm just going to paste Ralph's last post which I think is a good starting point for rd 2. Hope he doesn't mind that i'm quoting him to bring his very important thread back tot he point it merits.

"The thread was started with the intention of including some reason and logic to the screening/over diagnosis/overtreatment discussion. The statement from the Melbourne conference represents that in my view.

My wish is that their statement is an indication that reducing screening is not the best option for reducing the amount of overtreatment that currently exists and would be in detriment of the actual gain in mortality reduction associated with early detection and more effective treatment at such stage of diagnosis.

Their statement contains some important words for all of us to consider:

“An important goal when considering early detection of prostate cancer today, is to maintain the gains that have been made in survival over the past thirty years since the introduction of PSA testing, while minimizing the harms associated with over-diagnosis and over-treatment. This is already happening in Australia where over 40% of patients with low-risk prostate cancer are managed with surveillance or watchful waiting [10], and in Sweden where 59% of very low risk patients are on active surveillance. This is also reflected in current guidelines from the EAU, NCCN and other expert bodies.

Abandonment of PSA testing as recommended by the USPSTF, would lead to a large increase in men presenting with advanced prostate cancer and a reversal of the gains made in prostate cancer mortality over the past three decades.
However, any discussion about surveillance is predicated on having a diagnosis of early prostate cancer in the first instance. As Dr Joseph Smith editorialized in the Journal of Urology following the publication of the ERSPC and PLCO trials, “treatment or non-treatment decisions can be made once a cancer is found, but not knowing about it in the first place surely burns bridges”[11]. A key strategy therefore is to continue to offer well-informed men the opportunity to be diagnosed early, while minimizing harms by avoiding intervention in those men at low risk of disease progression. This consensus statement provides some guidance to help achieve these goals. “

Signatories:
A/Professor Declan G Murphy, University of Melbourne, Peter MacCallum Cancer Centre, Melbourne, Australia
Professor Tony Costello, University of Melbourne, Royal Melbourne Hospital, Melbourne, Australia
Dr Patrick C Walsh, The James Buchanan Brady Urological Institute, Johns Hopkins University, USA
Dr Thomas Ahlering, University of California, Irvine, School of Medicine, USA
Dr William C Catalona, Northwestern University Feinberg School of Medicine, USA
Professor Noel Clarke, Manchester University, The Christie Hospital, Manchester, UK
Dr Matthew Cooperberg, University of California San Francisco, Helen Diller Family Comprehensive Cancer Centre, USA
Dr David Gillatt, University of Bristol, Bristol Urological Institute, Bristol, UK
Dr Martin Gleave, University of British Columbia, The Vancouver Prostate Centre, Vancouver, Canada
Dr Stacy Loeb, New York University, USA
Dr Monique Roobol, Erasmus University Medical Centre, Rotterdam, The Netherlands

[10] Evans SM, Millar JL, Davis ID, Murphy DG, Bolton DM, Giles GG, et al. Patterns of care for men diagnosed with prostate cancer in Victoria from 2008 to 2011. Med J Aust. 2013;198:540-5.

Peace to all...

RalphV"

Davidg,
Well two of the names on that list will be on my 2:00pst afternoon conference call today...And they're both surgeons...

LOL

Why I oughta....

Tony

Ralf, my friend. Thanks again, for being the voice of reason in this debate, and forever keeping the focus on the men that would end up with advanced disease, but mostly for always remembering the nearly 40k men that die a year from this curse of a cancer.

I have got your back.

david in sc

I must have missed the first time. It's glaring now. THX...

Tony

one person here, a very outspoken person, actually loved the USPSTF recommendations.

Here is the consensus statement #4 that came out of Melbourne. This contradicts the recommendations given to us by the AUA in May:


4. Consensus Statement 4: Baseline PSA testing for men in their 40s is useful for predicting the future risk of prostate cancer. Although these men were not included in the two main randomized trials, there is strong evidence that this is a group of men who may benefit from the use of PSA testing as a baseline to aid risk stratification for their likely future risk for developing prostate cancer [7], including clinically significant prostate cancer. Studies have shown the value of PSA testing in this cohort for predicting the increased likelihood of developing prostate cancer 25 years later for men whose baseline PSA is in the highest centiles above the median [8,9]. For example, those men with a PSA below the median could be spared regular PSA testing as their future risk of developing prostate cancer is comparatively low, whereas those with a PSA above the median are at considerably higher risk and need closer surveillance. The median PSA for men aged 40–49 ranges from 0.5–0.7 ng/ml, with the 75th percentile ranging from 0.7–0.9ng/ml. The higher above the median, the greater the risk of later developing life-threatening disease. We recommend that a baseline PSA in the 40s has value for risk stratification and this option should be discussed with men in this age group as part of a shared decision-making process.

"Cancer Screening" by definition is done only when symptoms are not present. To say don't screen "asymptomatic" patients is redundant.

www.cancer.gov/cancertopics/screening

"Some types of cancer can be found before they cause symptoms. Checking for cancer (or for conditions that may lead to cancer) in people who have no symptoms is called screening."

The USPSTF is quite clear. They are calling to end all prostate cancer screening.

Tony

Yooper I agree. It isn't the AUA that is our enemy even though some have shown resentment towards them. If the USPSTF gets their way we would be wishing that we sided with the AUA.

www.uspreventiveservicestaskforce.org/prostatecancerscreening/prostatecancerfact.pdf

The AUA, and the response from the PCWC in Australia, are countered directly to the USPSTF recommendation. There are several points that align together between the AUA and the PCWC and none what so ever between them and the USPSTF.

I worry that the harder that pc advocates and patients push for more extensive and rigorous screening the more likely the USPSTF will be followed by insurers and the state and federal governments.

I worry also that we MUST find evidence based screening guidelines and stick together. And we must try to avoid catastrophic results through ODOT that are plaguing the prostate cancer industry epidemiology right at this time.

Tony

TC-LasVegas said...
Yooper I agree. It isn't the AUA that is our enemy even though some have shown resentment towards them. If the USPSTF gets their way we would be wishing that we sided with the AUA.

www.uspreventiveservicestaskforce.org/prostatecancerscreening/prostatecancerfact.pdf

The AUA, and the response from the PCWC in Australia, are countered directly to the USPSTF recommendation. There are several points that align together between the AUA and the PCWC and none what so ever between them and the USPSTF.

I worry that the harder that pc advocates and patients push for more extensive and rigorous screening the more likely the USPSTF will be followed by insurers and the state and federal governments.

I worry also that we MUST find evidence based screening guidelines and stick together. And we must try to avoid catastrophic results through ODOT that are plaguing the prostate cancer industry epidemiology right at this time.

Tony

Tony, I genuinely think the AUA recommendations towards men aged 40-54 are almost as dangerous as those issued by the USPSTF. I feel they threw my generation under the bus. I find the Melbourne Consensus much friendlier to my age group and certainly a much bigger ally than the AUA.

I don't know Ralph,

They are crystal clear to me. Why are you complicating this?


@Davidg,
Don't get too close to them David, The PCWC are also for targeted screening, active surveillance, and restraint from physicians to help control over treatment and I know you are steadfastly against all of the above.

Tony

lol.

I am not ascribing beliefs to you. These words are theirs not mine. If you don't know what doctor restraint is then OK I'll explain it.

"Prostate cancer diagnosis must be uncoupled from prostate cancer intervention through active surveillance of men with low-volume, low-risk prostate cancer." PCWC

The "uncoupling" is directed to physicians. It's calling on physicians to stop associating the diagnosis of prostate cancer with the need to treat it. It is a call for more restraint by the physicians after finding the presence of low risk disease...

That's reality.

They also say in their statements that while screening does save lives, it's mostly lives after the age of 50 where the biggest benefits are. That it's ok to get a helpful baseline in the 40's (Not specifically age 40) and that in the median of men in the 40's the best benefit is in the upper centiles versus the lowest centiles meaning 46,47,48, 49. They make no mention of a 40yo man in their comments.

Tony

Post Edited (TC-LasVegas) : 8/12/2013 5:39:26 PM (GMT-6)

Davidg Says:
"avoiding a baseline at 40 as the AUA proposed"

That is an embellishment. The AUA screening guidelines do not address the Baseline at 40 proposal in their draft which observed by many is not a screening event but an early diagnostic. The AUA does make possible a screening test at 40 available for those with high risk factors.

What's the difference?

Most of the proponents of "Get and Baseline at 40" do not regard this as a general screening. I personally do but that's not the context that the first baseline is considered in because they are not looking for cancer per se but elements that might make a monitoring for cancer more prudent.

The AUA has made no statement against it, and they have made a case for getting that first test at 40 as part of screening high risk patients.

Seems like the AUA is not out of synch with the PCWC much at all. I actually keep reading these statements between the two and they are very close...

Tony

Tony - I fear we are again going off on tangents and taking away from the scope intended by the OP. We are also continuing to get stuck on the same obvious differences of opinions that have been evident here for the last 3 months.

the AUA recommends screening for men 40-54 only in cases that are considered high risk.

"The Panel does not recommend routine screening in men between ages 40 to 54 years at average risk. I have some problems with this (as do many others). In addition to this statement, the AUA highlights its view that the likelihood of causing harm is high and that any benefit is marginal. It appears to have completely dismissed evidence (and its own previous view), that a baseline PSA in men in this age group is highly predictive of future prostate cancer, metastasis and death. In my view, there is considerable value in having a baseline PSA in this age group and I am disappointed that the AUA has not recognised the evidence to support this."

www.bjuinternational.com/bjui-blog/the-new-aua-psa-testing-guidelines-leave-me-scratching-my-head/

How the AUA and the PCWC treat men 40-54 is quite different in fact.