A proposed "model" for doctor-elderly patient dialogue on continued/discontinued PSA tests

In another thread ( HERE ), A Yooper posted results of a study which examined the subset of physicians who were continuing to administer PSA tests to men OLDER than 75 years.     Knowing that this is one of the scenarios that leads to prostate cancer over-treatment, the study sought to uncover whether there was good reason (or not) for these doctors to continue prescribing PSA tests.    They did not uncover any good reasons, and in fact they drew the dam*ing conclusion that “ the doctor’s tendency to order the test had little to do with 'measurable patient characteristic' ;” you know, the stuff right in front of him in his file.   [For complete clarity, the article was clear that MOST physicians are NOT following this practice of continuing to PSA test the elderly who have not been previously diagnosed with PC.   Some are still doing it; most are not.]     In A Yooper’s thread, I proposed a “model” for the doctor-patient discussion that could & should take place when a patient hits about 75, or about 10-15 years of remaining life expectancy and has not previously been having prostate issues…no issues to-date.   That model discussion came right off the top of my head, using wisdom and knowledge of a savvy PC layperson, but I recognize that there is opportunity for continuous improvement.   I’d like to throw it out there for comment, and possible improvements.   Vote in the poll , and then offer your value-added improvement suggestions.  Here's the original "model" dialogue (with a few minor tweaks):   "Bill (or Bob, or Joe, etc), as your doctor, I've been watching your health for a long time.  We've been testing your PSA for years, and you have consistently been below any threshold which would warrant any further investigation.  We've talked in the past about how prostate cancer is increasingly ubiquitous among aging men, but the vast majority are slow growing.  For a man your age, after 75 years, to suddenly grow a rare, aggressive prostate cancer is virtually unheard of.  Based on studies, the reality is that you probably have some sort of low-risk variety in your prostate now, but based on the measurable patient characteristics which I have collected in your file for years had have right here in front of us, it is likely the kind that stays indolent and causes no harm.  Men 75 or older are at elevated probability of both direct and indirect complications and risks from treatment.  Every single medical group on the face of the earth says that the right thing to do is to put your excellent history of PSA away in your file and simply stop testing it and stop worrying about it and go enjoy life; and besides, I would never recommend you for any aggressive treatment whatsoever if we did find anything at this point.  What do you want to do? "         Post Edited (Casey59) : 10/16/2013 1:32:21 PM (GMT-6)

So far, no suggestions for improvement.

This was written completely off the top of my head...certainly there is room for improvement...?

 

 

I would never recommend you for any aggressive treatment whatsoever if we did find anything at this point.  What do you want to do?"

 

Patient:  Here's what I'd like you to do.  I'd like you to continue to give me the PSA test until my general health includes other conditions such that it's no longer warranted.  I want you to continue to monitor my PSA level, just as I expect you to continue to monitor my blood glucose, my triglycerides, my cardiac health, my liver enzymes, and those other tests we've been doing for years.

 

If and when my PSA results indicate a potential problem, I think I deserve to at least be aware of it....to know that something may be amiss in my prostate.  I don't need you shielding me from the "worry and anxiety" you think that the knowledge that I might have prostate cancer, or at least prostatitis, might cause me.  That's not your function.

 

If I should happen to have prostate cancer, and as you say, there's a good chance I have at least an indolent variety right now (though apparently it has never manifested itself thus far in my past PSA results), then we can talk about where to go from there.  I understand it's likely that aggressive treatment will be contra-indicated, but darn it, it's my life, my body, and just as I want to know about other threats to my health, I want and deserve to know about this one.  If I should happen to have an aggressive or advanced case of prostate cancer, I want to know about it so I can mentally prepare myself for the fact that my life may end this way.

 

You're my doctor.  It's neither your duty nor your right to shield me from the unpleasantries that accompany my growing old and dying.

 

Oh, by the way, I'm going to be looking for a new doctor.  I'll let you know where to send my files.

Casey,
There are 7.3 million males in the US 75 years and older. Of those, 6,139 are diagnosed with prostate cancer each year and some 2,365 die of the disease.

The current guideline is not to test 70 yo or older men with PSA. In a conversation with 75 yo and older men, they should know that as many as 7.9% men of their age and older die of the disease each year in the US. I think that when told that they might make a better decision.

RalphV

Hi Ralph:

A clarification please...of the 2,365 75+ men who die of PCa each year are those deaths also men who were DIAGNOSED at 75+ or do they include men who were diagnosed earlier than 75?

Thanks,

Jim

"The current guideline is not to test 70 yo or older men with PSA. In a conversation with 75 yo and older men, they should know that as many as 7.9% men of their age and older die of the disease each year in the US. I think that when told that they might make a better decision."

I'm sorry, but this is not correct about what's being recommended. The current AUA guideline "Statement 5" is to not test men over 70yo who are not otherwise healthy. Like other organizations. If they are healthy and have a decent life expectancy the current guideline leaves the door open on a case by case basis.

It's important to note that half of the men who die this year are over age 75. However that does not indicate that screening at this age would be effective on them. As we all know it takes years for PCa to manifest to the point of mortality. The most effective years of screening these men for life saving benefit is likely over by age 70. That stated...I do agree with telling men that 7.9% of men this age - and over - die each year. However...They may have missed any life saving benefits of screening at this age. Data suggests little life saving benefit in men who do not have otherwise good health.

The USPSTF is the only organized recommendation that says not to test any 70yo men. But they also include that every man should not be tested.

Tony

Post Edited (TC-LasVegas) : 10/18/2013 12:26:13 AM (GMT-6)

Who says doctors are blinding administering PSA tests to patients? Seems to me that is fallacy of composition.

One of the reasons we go to doctors is to get their advice and not just their medical advice. When we get diagnosed with any serious disease we might not be thinking clearly. The doctor is.

"There are 7.3 million males in the US 75 years and older. Of those, 6,139 are diagnosed with prostate cancer each year and some 2,365 die of the disease."

So by testing, and treating, these men one could potentially save/extend their lives? If that's the case, and I believe it is, then it is worth every penny and then some.

You know, these government (and other) recommendations - and the click clack surrounding them - remind me more and more of the three strikes and you're out laws.

I guess I should also state the obvious :    The post-treatment management of PC is a completely different scenario, and is very dissimilar from the man who reached 75 with years of normal PSA and no prostate issues.   A man actively being treated for PC would not stop getting PSA tested when crossing 75 or any other age threshold, except perhaps when receiving purely palliative treatments while in final stages.       gunfighter – I’d like to make it very clear, sir, that the scenario I described is for a man who has a long track record (“for years,” was, I believe, the phrase I used) of normal PSA test results and no prostate issues in his past.   (This, obviously. does not describe you, or your scenario.)   I would go on to say that if the man in my stated hypothetical scenario has multiple comorbidities and less than 10 years LE, then all the more reason to end the PSA testing and encourage him to focus on other more important things that something that will never bother him.     Ralph, as others have already pointed out here, the figures you provided serve no end in this scenario except to propagate obfuscation.   They have no bearing on the decision for a 75 year old with years of normal PSA and no prostate issues.   The PC growth, metastisis and eventual death is measured not in months or years, but in decades for all but the few rare uber-aggressive cases…and those few rare uber-aggressive cases are, frankly, unstoppable anyhow by any medical means.   The fear-generating obfuscation is what I would expect from a create-fear then rush-everyone-to-overtreatment surgeon (Spamadi comes to mind, except he markets himself to the young & naive).   I am (again) disappointed that you have resorted to such fear-mongering tactics. By the way, I think you also failed to provide appropriate perspective with your figures…a half million men over 75 die every year from all causes.     As I’ve said a zillion times, there is no room in medicine for a “one-size-fits-all” approach…not here, or anywhere.   That is why we have “Guidelines,” not “Rules.”   It is also why doctors need to have a “dialogue” with patients for joint decision-making, as I have encouraged here .   Decision-aides are being made to help both physicians and patients with those discussions…   (Buddy Blank, the answer to your question is here, in this paragraph)        

I just took a few minutes and went back and re-read that older thread which Ralfinaz mentioned in his last comment.  At one point in that thread, Ralph said, "Developing a balanced informed consent form would go a long way in providing men with their options. Such forms exist now but in my opinion are so biased that any man in a normal state of mind, after reading them, would never accept to be tested."

My objection to Casey's proposed "dialogue," is that there's a definite bias in the doctor's lengthy speech to his "patient," just as Ralph finds obvious bias in the current consent forms.  In all of this, the clear underlying message is  "Don't get tested." 

In Casey's scenario, the doctor spends a good deal of time lecturing the patient on the inadvisability of the PSA test, essentially telling him to stop worrying about prostate cancer, and then asks the patient "What do you want to do?" as if that question somehow provides a balanced and appropriate perspective. 

Just for clarification, am I to understand that the sudden, aggressive onset of prostate cancer at age 75, or 76, or 77 cannot be dealt with in some way? No radiation therapy?  No hormone therapy to delay progression?  Just hope you die in your sleep of a sudden cardiac event before a protracted bout with prostate cancer? 

 

Post Edited (clocknut) : 10/18/2013 10:06:04 AM (GMT-6)

clocknut, I believe I took your question into consideration  (but let me know if you have a suggestion for improved wording ): "...Every single medical group on the face of the earth says that the right thing to do is to put your excellent history of PSA away in your file and simply stop testing it...    What do you want to do? " Clearly, there is a recommendation from the doctor (with the backing of the medical profession), but the choice is ultimately the patient's.  Would you want a recommendation on a topic like this from your doctor, or do you want him to sit on the fence and say, "I dunno."? Everyone clamors for "a man's right to know."  Well, if a man wants to do something that the medical profession recommends against, then I suppose he has a right to do what he wants...this this sentence (above) provided for that. [Personally, I think that having someone else pay for needless procedures is NOT a right; it jacks up taxes and insurance rates.] Post Edited (Casey59) : 10/18/2013 10:21:24 AM (GMT-6)

Oh geez, not the "I will not pay a nickel to save a 75 year old's life because this insurance company's actuarial table states he will die anyway" stuff again.

Does this have any place at HW? I am surprised the guy who said it isn't banned.

I mean Christ - Halloween is a few weeks away yet.