Why men should still consider a PSA as a baseline test...

In spite of a totally negative recommendation by the USPSTF and limitations by other medical associations, men should be informed that the PSA test can save their lives as they age. In May at the annual American Urological Association meeting a new study will support the use of PSA as a way to reduce prostate cancer mortality and at the same time reduce unnecessary treatment. It is not a new discovery. It is just a reaffirmation of what has produced the reduction in PCa mortality experienced in our country and other countries of the world.

The study in question demonstrated a reduction of metastatic disease at diagnosis of 27% and a 43% PCa death reduction by the use of PSA screening. We always hear that 1000 men need to be screened to avoid a prostate cancer death. Well, this study with a followup of 15 years reports that 16 men need to screened and 3 diagnosed to prevent a PCa death, Are you listening USPSTF? Are you listening AUA?

The study concluded:
"The ratio of benefits to harms of PSA screening varies dramatically with levels of PSA in blood at age 60. Previous estimates of the
effect of PSA-screening have been an average of very different subgroups with low and high risk. Our data suggest that men with a
PSA < 1 ng/mL at age 60 could be exempted from further continuous screening. Screening men with a PSA 1-2 ng/mL needs a
discussion between the patient and his doctor. Continuing to screen men with PSA > 2 at age 60 seems very beneficial, with the
number needed to screen and treat being extremely favorable."

Seems reasonable and avoids PCa deaths!

Source:
PROSTATE CANCER SCREENING
Sigrid Carlsson*, Melissa Assel, Daniel Sjoberg, David Ulmert, New York, NY, Jonas Hugosson, Gothenburg, Sweden, Hans Lilja,
Andrew Vickers, New York, NY
Abstract: MP69-11

RalphV

Ralph, as Gunfighter said, thanks for another very reasonable perspective on the PSA issue.

I can only say that my prostate cancer would have gone undetected and untreated had it not been for a primary care physician who included the PSA test each year with my annual physical. I had the typical male "bulletproof" mentality, and it simply never occurred to me that I could actually have cancer. The PSA upward trend led me to the biopsy and then to the prostatectomy.

Meanwhile, my five brothers have also been routinely PSA-tested. We range in age from 56 to 70. Only one of them (now 70 years old) has shown any elevation in the PSA numbers, and none of them has required treatment for prostate cancer, though my older brother has had a couple of biopsies. I would have to say that none of the five of us has been overdiagnosed or overtreated, and we're all seeing different physicians in different areas of the country.

In other words, the PSA test has caused us no harm, and it sounded the alarm that led to the detection of my Gleason 7 prostate cancer before it escaped the capsule.

I guess critics of PSA testing would say, "Well, then, four of your brothers did not need to be tested." I think that's a ridiculous statement, but that appears to be the argument.

It would be interesting to see a study that would reveal the percentage of "experts" opposing PSA testing who, in spite of their public stance, privately make sure that they themselves are tested annually. I suspect the percentage would be extremely high.

As usual, you got my vote on the subject, and I appreciate your continuous work to keep drumming out the beat for continued PSA testing.

I still don't like any of the motivations, open or hidden, on the other side of the argument.

Let's keep finding ways to save me, and to lower the ultimate PC death rate.

David

Tony Crispino said...
Ralph,
I posted this here a year ago but it's appropriate to post it again in this thread. It is by two of the authors of the papers you have referenced.

www.medscape.com/viewarticle/805678

Hi Tony,
Drs. Vickers and Carlsson are two of the authors of the studies mentioned in this thread. Their 2013 video at the 2013 AUA Annual meeting presented a general view of the differences between diagnosis/treatment in Sweden and the USA. The video mentions PCa overtreatment here and more AS in Sweden than here. Both facts are correct based on less use of PSA testing in Sweden than here. What the video fails to mention is that Sweden has one of the highest PCa mortality rates in the World and prostate cancers are diagnosed there at more advanced stages than in the USA. This all related to more testing with PSA here than in Sweden.

That said, the two studies mentioned that will be presented in May of this year at the AUA Annual meeting support the notion that a PSA level lower than 1.0 ng at a young age has value in predicting the future development of more aggressive disease. If such is the case, then it makes sense to baseline PSA with the assurance that most aggressive cases will be caught and those with less aggressive disease would be spared in the future. This is the way the EU is following. Here instead of proceeding with caution and establishing a valid and supportive AS protocol that provides patients with a certain degree of safety in avoiding progression many men are treated prematurely and suffer the SEs of treatment causing overtreatment.

I continue to support men who qualify for active surveillance with the understanding that progression is possible if given time and the need for them to be followed by a supporting physician who will monitor the patient responsibly. The conditions are not always currently available to our USA patients.

I hope that at least the AUA reviews the current evidence and supports the notion that a targeted baseline PSA can provide much benefit to many currently uninformed males who are subjected to confusing guidelines as they age. Thanks for the link to the video.

RalphV

You're welcome Ralph.
Not sure why it's appropriate to lump the AUA and the USPSTF together being that the USPSTF is 100% against screening any man and the AUA is 100% for screening every man during his lifetime. I am certain that what has your concern is that the AUA is recommending a targeted approaches to screening but so are both Vickers and Carlsson who is from Sweden and I am certain she understands the nuances between Sweden and the US where she works now at MSK with Vickers.

Carlsson acknowledged that the inclusion criteria in Europe was in older men that would definitely better benefit from screening than younger men. Many men in the Europe studies never had a first PSA until age 67. You will find more life saving benefit at that age than you would at age 40. When I saw her speak at ASCO last year she was very much concerned about lowering screening ages if nothing was done to curb over treatment and improve outcomes when treatment was applied. Both Vickers ad Carlsson suggest that if treatment is to happen it needs to get out of the community centers and into the high volume centers.

That said the topic here is baseline screening and I see no issues with it as long as a conservative approach is part of it and it's based on science and not consensus. Most suggestions of a baseline model suggest that if a man is below a certain threshold that he should not be screened again until he reaches 50 (see NCCN and MSK guidelines). This can leave a gap of up to five years. The AUA suggests that high risk men be screened as low as 40 and not be tested annually. All of these approaches require a less aggressive approach to instances where these screenings lead to a diagnosis of low risk disease.

The AUA has selected it's panel for treatment guidelines and because I am on it I can't discuss guidelines from the AUA. I can say that it will be a very interesting next year and a half. I can also say that the NCCN did a great job on their guidelines for both screening and treatment in my eyes.

advancedpcatalk.freeforums.net/thread/81/new-2014-nccn-guidelines

There are some issues with the data they used but the use of AS is noted to be far safer than previously assumed. There would be no argument from me in high risk cases and most intermediate cases that treatment is necessary.

What to do with the low risk cases is where the controversies are.

I listened to Dr. Carter's presentation and found it enlightening. However, I must admit I cringed a bit when he spoke of "...the harm caused by a PSA test...". I think most of us get that PSA tests lead to biopsies and biopsies sometimes lead to treatment and some of that treatment is overtreatment. But, I personally think the medical establishment is focused on the wrong end of the spoon. They have spent years talking and arguing about who should get a PSA test and the if's and when's of that proposition. Geez...am I so simple minded that I don't think that is the problem? IMHO, the "decision guide" that the AUA and others should provide should be for what happens AFTER the PSA results are known.

For example, many knowledgeable members of this forum will suggest that a new patient should get a PCA3 test prior to biopsy. Also, that a course of antibiotics be given for a suddenly elevated PSA rather than immediately rushing off for a biopsy. How come that isn't SOP from the AUA or some other august body?

And, most of us will recommend that a post-biopsy patient get a second reading on his slides from an expert? How come that isn't SOP from the AUA or some other august body?

And, I think most of us have come around to thinking that confirmed G6, low %, low number of cores, low PSA score patient should be treated via AS as a starting point rather than being rushed into being cut or burned. Why doesn't the AUA or some other august body say that other treatments are INAPPROPRIATE for such a patient rather than just talking about patient-doctors discussions?

I don't think this should be this hard....

Jim

Ralph,
We are very close to common excellent ground here but you made one statement that I say I disagree with.

"The major argument here is that overdiagnosis and overtreatment has been given priority over reducing prostate cancer deaths."

The AUA, ASCO, AMA, ACS, JHU, MSK, UCSF, NCCN and just about any association without the letters USPSTF in them do not place morbidity ahead of saving lives. If they did they would agree with the USPSTF and that would be the end of the discussion. They are, however, placing priority on saving lives with sensible and hopefully scientific approaches to reducing morbidities. And this is no easy task.

I believe there are no perfect guidelines. Nor will there be. But I also believe, and fully agree with you, that the confusion is problematic. But it's no different in other countries in that regard. Stating that various studies show between 22% and 42% reductions (quote from Carlsson) in mortality show a wide disparity even in agreement that PSA can save lives. Many things affect these numbers including inclusion criteria, and the psychosocial approaches to prostate cancer in various countries, and also the level of evidence provided that indeed is affected by a mixture of science and bias.

By my take home is that all four members of the above videos are AUA members. And all four stated that there is a real need to continue to evaluate current practice in the US and make PSA screening and diagnosis safer and better. They all want to catch dangerous disease and they all want to see indolent disease handled differently than in the past. And this is consistent with the organizations I listed.

To that regard there is a consensus with these groups.

Tony said, "
The AUA, ASCO, AMA, ACS, JHU, MSK, UCSF, NCCN and just about any association without the letters USPSTF in them do not place morbidity ahead of saving lives."

I don't even know what this means, and I have a Master's Degree in English and have taught at the college level.  I'm not faulting you, Tony, but this kind of "medical speak" is just impossible for lay people to understand, and I'm not sure it makes that much sense, anyway.  Maybe someone can explain in clear, concise language what it means to "place morbidity ahead of saving lives."  And is this really an either/or proposition?

Tudpock's comments (see above) resound with common sense and a clear understanding of the relationship between getting a blood test and deciding what, if any action, should follow a bad result on that test.

I think I said as long as three years ago that all this seems like a case of "Ready, fire, aim."  The PSA is a blood test.  It doesn't even offer a diagnosis, just an indication that further investigation may be warranted, or that perhaps another test should be given in a year or so.  A biopsy may or may not be suggested based on the result. 

Instead of constantly bickering about the PSA test, we should be demanding that urologists and oncologists be more conservative in their treatment of suspected prostate cancer.  They should avoid the rush to surgery or radiation.  I don't have any problem with suggesting a biopsy based on a PSA result, but I do have a problem with rushing Gleason 6's with extremely small volume tumors into major surgery.  That's where we should be focusing our attention.

Obviously I'm not an expert in the field of urology, but I am absolutely dismayed by the amount of energy that is wasted....simply wasted...in agonizing over the PSA test. 

 

Post Edited (clocknut) : 4/9/2014 3:26:05 PM (GMT-6)

Thanks, Tony. I'm used to seeing "morbidity" used as in definitions #1 and #2, but not so much in #3.

For example, we often talk about co-morbidities clouding the decision on whether or not to have treatment (e.g., a person with diabetes might not be a good candidate for certain procedures).

I often think in terms of analogies, and I know that's not always a good thing to do, but in regard to the PSA test, it's almost as if some folks are saying...."ya know, my car's headlights don't do a perfect job of lighting up the road ahead so that I can see every danger at night. I find myself worrying that maybe there's a deer out there that that I'm not seeing, or maybe a car in my lane with none of its lights working that I might crash into. This causes me a lot of anxiety, so to avoid worrying, I'll turn off my headlights and not use them.....or simply stop driving at night."

I say, use the headlights, but understand their limitations and proceed accordingly.

Post Edited (clocknut) : 4/9/2014 4:15:27 PM (GMT-6)

Thanks, Ralph. PSA testing won't go anywhere until better tests come along. The AUA guidelines, although better than the Brawley's ones would still throw many men, albeit a small percentage, under the bus. Men like me.

Shame for dramatic goodbyes and shame the advocates forum doesn't pick up steam. I think it would be a great alternative place for some. Perhaps a sticky thread up top to direct people who are interested in such stuff there so it doesn't have to get advertised on each and every thread here that touches on a topic that is of interest to the mission there.