USPSTF PSA screening guidelines result in higher Gleason score diagnoses

Shocking, just shocking! Boy was that hard to predict. Unfortunately it’s probably just the tip of the iceberg for advanced PCa cases that are surely headed this way.

This is bogus. I'm not saying USPSTF was right, I'm just saying this is not the way to analyze it. The point of anti-universal screening is to eliminate PSA testing and consequent overtreatment in men with low grade, insignificant cancer. So if the insignificant GS6s are eliminated, the percent of total has to shift to higher grades. But that does not mean that the GS8-10s are not being identified on a timely basis.

This study also does not in any way look at which of those high-risk men would have been identified if they had followed an early screening policy. In fact, looking at the age distribution, there was no meaningful change; in fact, the median age at PSA testing went down slightly - testing occurred at a younger age. That implies they were not getting tested "for cause"more in 2014, since virulence and symptoms increases with age. And with 20% of PSAs missing in 2011, it's impossible to say if they were being sent for biopsy at a higher PSA - it looks like there was no real change.

Again, I'm not defending the USPSTF policy - which I think was wrong. but this isn't even close to the analysis that proves it wrong.

PSA screening is very good at picking up low Gleason and over diagnosed cancers as well as high Gleason cancers. This result is not surprising in the slightest and isn't news.

RCS said...
1.) What is your basis for claiming only the “insignificant GS6s” were removed. Seems that all grades would have been removed in proportion to the original population.

The whole purpose of early screening is to diagnose cancers early in their development, while they are still low grade and insignificant in size. The argument against it is that diagnosing those low grade, insignificant cancers, only causes anxiety and overtreatment without any survival benefit. By following USPSTF guidelines, we would expect to see the number of low risk diagnoses go down relative to the other risk groups - that's the entire purpose of those guidelines.

RCS said...
2.) i am not sure what you mean by “meaningful”. The authors state that the age decrease is statistically significant.

"Statistically significant" is not the same as "meaningful." Statistical significance has to do with confidence that a difference, however small, is real. It is because of the sample size that it is more statistically significant. Meaningful is a subjective judgment related to whether a difference is likely to have an impact. So, although patients were 1 year younger in 2014 (if they were following the USPSTF guidelines, they would be older, not younger), I wouldn't characterize the difference as meaningful.

43.45% of all statistics are made up on the spot.

RCS-

Reducing testing of all PCs equally across the board was not the intent of the USPSTF guidelines, or the AUA or any other PSA guidelines. The intent was to preferentially reduce the number of low grade, insignificant PCs being PSA tested. Everyone agrees that we only want to test those men who need to be treated. Detection of grade and size increase over time with age, so by detecting earlier, they were preferentially detecting lower, insignificant cancers. By 2011, after universal PSA testing had been in place for about 20 years, the vast majority of newly diagnosed cases were low grade and insignificant. Eliminating those from the mix, necessarily increases the percent that were higher grade.

Todd said...
Better to be over treated than to end up at stage 4

Those were your alternatives, but they are the alternatives for most men. As you know, your case is unusual. For most men, the alternatives are overtreatment with high risk of impotence and incontinence, or end up living with the kind of cancer for some time or forever that will never kill them. The hope of a rational testing policy is to distinguish the rare cases like yours from the more typical cases.

I am on the other end of the PSA spectrum with a low initial PSA of 2.1.
My Primary Doc's yearly examination was missing a small lump, but was luckily felt by an emergency room doctor one day.

halbert said...
As we went round and round about this when the screening guidelines came out 2 years ago, the key point is really about education...both for doctors about what PSA means (and doesn't mean)...and for the doctors to then actually educate their patients. At least that's my take.

Todd's story is a cautionary tale....and there are many more like him.

There is no reason why testing has to lead to over treatment, or to any particular type of treatment, or treatment at all, is there?

The trick is to stop doctors from pushing surgery or any treatment to the low risk cases and to keep patients from demanding treatment- right now- when they hear the word "cancer". The education required for this might be daunting. But it can be done. After all, they educated us well enough to get our DREs and PSAs at a certain age. We had TV programs, Al Roker and Matt Lauer, etc, were getting their DREs on TV! That was one extreme, surely we can educate about the dif in low risk vs medium to high, and prevent over treatment, without sacrificing the guys who won't be tested until there is some kind of symptom? (or whatever exactly the new recs are? )

If over treatment is a problem, and I surely think it is, then move aggressively to stop the over treatment, instead of stopping early detection for the high risk guys. Maybe we should start to look at over treatment of low risk cases as malpractice? The threat or possibility of law suites has altered many a medical practice. Not always for the good, but it can and does change things quickly. Seems preferable to me than just not even looking at men because most of them might end up diagnosed either as no cancer or as low risk unless you wait for symptoms.

My DRE was negative on a general physical(do they still do them under the new standards). There was a debate with my PCP about rather to do the PSA or not, this was exactly 4 years ago. I knew about the evolving standards, and the possible problems that might come from testing, and I didn't want it. My PCP said it was up to me, but he leaned towards getting them, having just lost a step dad to PC. I went with his suggestion and got it. Though the DRE was negative, it was not when the URO repeated it, and my PSA had gone up from 8 point something to 10.9 in 3 weeks, despite antibiotics.

I don't see how I could have benefited from delaying that PSA until some symptoms developed. Rather, I wish I would have more PSAs earlier and paid more attention to them. I don't see why they should not have been recommended for me just because docs don't want to explain to the low risk guys that they really have little to worry about and plenty of time to watch it, or even worse because some of them want to push for unneeded treatment. It absolutely makes sense that if you delay testing of guys like me until there is some type of symptom to indicate the need for testing, that more of us are going to die. Unless I am not understanding the new guidelines? Have the guidelines been changed since 2012?
www.aafp.org/news/health-of-the-public/20120522psascreenrec.html

Somebody said...

AAFP, USPSTF Issue Final Recommendation Against Routine PSA-based Screening for Prostate Cancer
Evidence Simply Does Not Support Test's Benefit, Says Task Force Co-chair

May 22, 2012 04:00 pm Matt Brown – The AAFP is recommending against performing prostate-specific antigen (PSA)-based screening for prostate cancer in asymptomatic men, a position that is in line with a final recommendation(www.annals.org) from the U.S. Preventive Services Task Force (USPSTF) that was published May 22 in the Annals of Internal Medicine.

The recommendation applies to asymptomatic men in the general U.S. population, regardless of age, but does not include the use of the PSA test for surveillance after diagnosis or treatment of prostate cancer.

According to USPSTF Co-vice Chair Michael LeFevre, M.D., M.S.P.H., a family physician from Columbia, Mo., it all comes down to the numbers. More than 300,000 men have been enrolled in randomized screening trials in nine countries, he told AAFP News Now, and, after 10 years of follow-up, "the hoped-for benefit is not apparent."

Doug Campos-Outcalt, M.D., M.P.A., of Phoenix, the Academy's liaison to the USPSTF, said that although he knows the report will cause controversy, the evidence against using the PSA screening test in asymptomatic men is clear.

"The simple fact is that most men who are found positive for prostate cancer through screening are not really benefitted by it at all, because the tumors are not aggressive," said Campos-Outcalt. "But oftentimes, these patients go on to receive treatments as if they were battling aggressive disease."

Well, that right there, that last sentence, is what must be corrected. The problem is not so much the screening, it is the overly aggressive response to the screening.

One thing I have never understood. Haven't deaths from PC plummeted during the PSA era? If so, then it seems to me the hope for benefit is indeed apparent, despite what the above recs say. But I suppose they are saying that is due to improved treatments during the same time period?
/seer.cancer.gov/statfacts/html/ld/prost.html
Death per 100,000 in 1993: 39.3 vs 19.1 2014! That is a very impressive drop. It drops significantly every year starting immediately after 1993, after steadily increasing from 1975-1993. Isn't that about the same year that PSA test were just staring to come into wide spread use? Should we expect to see death rates increase with less testing?

Post Edited (BillyBob@388) : 11/23/2017 9:45:01 PM (GMT-7)

BillyBob,

I could not have stated my views on this matter anymore clearly than you have. I would add that I have trouble understanding the “ethics” of following a policy where it is KNOWN that a group of men will die from prostate cancer in order to save another group of men from harm, harm from themselves and harm from their doctors. The tragedy is that the harm is completely avoidable. Over treatment doesn't have to happen. Apparently, another “problem” with widespread screening is the “anxiety” generated in men who have to live with the knowledge that they have low risk cancer. lol. I'm sure the anxiety is real, but I think they can learn to live with it, especially if it allows the lives of other men to be saved. Maybe the current screening policy is ethical from the standpoint of public policy, but I have a hard time seeing it.

As can seen from my signature this issue has affected me directly, so my views may be slanted. I am not bitter. I try to focus on the future because dwelling on the past doesn't help anyone. I do keep that first line in my signature to remind people that the USPSTF policy doesn't just exist in the abstract. It has real effects on real people.

More information is always better, as long as that information is not misused. The main problem with PSA testing is the overtreatment, which should be tackled aggressively, but how to do that? This is hardly a unique problem in medicine, where profits to doctors align with the fears of patients to produce expensive treatments with poor relative outcomes (compared to a different, less expensive course of treatment).

I ran across this article trying to address the economic benefit of various PSA testing and PSA-based biopsy thresholds, both for current treatment percentages and for more selective treatment, pushing more low-risk patients into surveillance. It turns out that the best approaches involved PSA testing with low thresholds for triggering biopsies, but only if selective treatment is applied.

the many shall suffer for the few.