PSA Screening Redux

Kongo

At the risk of beating a dead horse, I thought it noteworthy that Dr. Otis Brawley, the Chief Medical and Scientific Officer for the American Cancer Society (the organization that sponsors this forum) has come out strongly against PSA screening in light of the USPSTF draft report.

I thought it would be of interest to those with strong opinions about this controversy to see what Dr. Brawley has to say about it. His Op-Ed was published on CNN Tuesday and is quoted below.

"(CNN) -- The recent news that a group of highly respected medical experts, the U.S. Preventive Services Task Force, is considering advising against routine prostate cancer screening shouldn't have come as too much of a surprise to anybody. Indeed, the fact that so many people now are claiming to be surprised is an interesting story. Many respected organizations that issue screening guidelines have for a long time expressed concern about the effectiveness and known risks of screening for prostate cancer.

The list of groups that have expressed caution about widespread use of the prostate-specific antigen test, known as PSA, includes the American Urological Association, the National Comprehensive Cancer Network, the European Urology Association and the American Cancer Society.

Here is the problem in a nutshell: Widespread PSA screening began 20 years ago, amazingly, well before anyone bothered to initiate studies to find out whether such screening saves lives. Because doctors and patients believed that screening works — wasn't it obvious that it would? — they opposed rigorous studies, called randomized trials, that assign half the patients to get screening while the other half goes unscreened. Despite opposition from doctors and patients, the trials finally got done, and today the harms of screening are better proved than the benefits. A substantial number of men receive unnecessary treatment, as their cancers are so slow-growing they are not life-threatening. These treatments commonly lead to harms such as impotence and incontinence and can even lead to premature death. This, while the benefits -- the number of lives saved -- are very small at best, nonexistent at worst.

Alas, the history of medicine is filled with examples of physicians jumping the gun, acting in a manner unsupported by evidence, even ignoring the words of caution in the "evidence-based guidelines" promulgated by their own professional societies.
I am convinced that most advocates of screening and aggressive treatment are motivated by genuine desire to benefit men. Unfortunately, they are uninformed or unwilling to believe the reality that early detection and aggressive treatment of cancer is not always the best thing.
For two decades, some supporters of prostate cancer screening, even some so-called experts, have overstated, exaggerated and, in some cases, misled the public about the evidence supporting its effectiveness. They downplayed or failed to mention the risks of screening and misapplied and misstated basic principles of cancer screening.

With evangelical fervor, true believers conducted mass screening in shopping malls, at state fairs and in supermarket parking lots. Screening has been sponsored by medical practices, hospitals, drug and medical device companies, politicians and even manufacturers of adult diapers. Most of these sponsors wanted to do a public service, but many profited from it. Some may also have been blinded by that profit.

The phenomenon of so-called experts, who do not understand basic principles of screening, making exaggerated statements is not limited to prostate cancer. It also occurs in breast and lung cancer screening. Well-designed scientific study has clearly showed that these procedures save lives, but science has also demonstrated that the procedures have limitations and risks of harm.
The Task Force, an independent board of experts in interpretation of medical evidence, convened by the U.S. Agency for Healthcare Research and Quality, sanctioned true screening experts to review and assess every published scientific study concerning prostate cancer screening. This recently published review is very reasonable. It recognizes that the few studies that suggest that prostate screening saves lives are undermined by biases and inconsistencies. Of course, the studies that did not show a benefit to screening also have flaws. However, all studies consistently show that significant harms are associated with screening and the sometimes unnecessary treatment.
Ironically, the Task Force recommendation isn't too far apart from that of the American Urologic Association, which represents most of the doctors who diagnose and treat prostate cancer. The association's 2009 publication titled "PSA Screening Best Practice" reads: "Given the uncertainty that PSA testing results in more benefit than harm, a thoughtful and broad approach to PSA is critical. Patients need to be informed of the risks and benefits of testing before it is undertaken. The risks of overdetection and overtreatment should be included in this discussion."

While the Task Force statement is wise and reasonable, there is risk that the pendulum will swing too far. A move against all use of the PSA tests in screening and diagnostics would be unfortunate. The Task Force review does see some benefit to prostate cancer diagnosis and treatment. Guarded use of PSA testing as a diagnostic tool in select individuals within the physician-patient relation is reasonable and consistent with the U.S. Preventive Taskforce statement.

Cancer screening is complex. Some outspoken clinician advocates of screening need to understand that complexity. We need balanced, truthful information widely available to physicians and patients. Sadly, the overselling and overpromise of screening technology in cancer and other diseases harms patients and — justifiably -- weakens trust in the medical profession. It also adds to the unnecessarily high cost of health care, which is already threatening the health of the U.S. economy.

More than anything, the battle over prostate cancer screening raises a disturbing question: Are we as a society prepared to pay attention to scientific evidence?"

The link to this opinion can be seen at: http://www.cnn.com/2011/11/01/opinion/brawley-prostate-cancer-screening/index.html and the comments by online readers are interesting, to say the least.

K

Beau2

Dr. Brawley's Opinions
Hey Kongo,

Thanks for the posting the doctor's opinions. I found them interesting. It appears to me that Dr. Brawley is confusing PSA testing and PCa treatment.

Dr. Brawley is quoted as saying,

"Sadly, the overselling and overpromise of screening technology in cancer and other diseases harms patients and — justifiably -- weakens trust in the medical profession. It also adds to the unnecessarily high cost of health care, which is already threatening the health of the U.S. economy."

In the case of PSA testing, I do not see how the test physically harms the patient, nor do I see anyone overpromising or overselling the test. I do see doctors overtreating and overpromising the results of the treatment ... PCa treatment is a big business.

Also, there is no way that PSA testing threatens the health of the U.S. economy ... I don't even think PCa treatment threatens the U.S. economy.

I feel Dr. Brawley has knowingly confused the science of PSA testing with the economics of PCa treatment, and has thrown in some economic scare tactics to boot. These scare tactics are what "weakens the trust in the medical profession" and science in general. If his concern really is "the unnecessarily high cost of health care, which is already threatening the health of the U.S. economy", I would suggest he focuses on the large medical costs ... like doctor's salaries. PSA testing costs are dwarfed in comparison.

Kongo

Beau2 said:

Dr. Brawley's Opinions
Hey Kongo,

Thanks for the posting the doctor's opinions. I found them interesting. It appears to me that Dr. Brawley is confusing PSA testing and PCa treatment.

Dr. Brawley is quoted as saying,

"Sadly, the overselling and overpromise of screening technology in cancer and other diseases harms patients and — justifiably -- weakens trust in the medical profession. It also adds to the unnecessarily high cost of health care, which is already threatening the health of the U.S. economy."

In the case of PSA testing, I do not see how the test physically harms the patient, nor do I see anyone overpromising or overselling the test. I do see doctors overtreating and overpromising the results of the treatment ... PCa treatment is a big business.

Also, there is no way that PSA testing threatens the health of the U.S. economy ... I don't even think PCa treatment threatens the U.S. economy.

I feel Dr. Brawley has knowingly confused the science of PSA testing with the economics of PCa treatment, and has thrown in some economic scare tactics to boot. These scare tactics are what "weakens the trust in the medical profession" and science in general. If his concern really is "the unnecessarily high cost of health care, which is already threatening the health of the U.S. economy", I would suggest he focuses on the large medical costs ... like doctor's salaries. PSA testing costs are dwarfed in comparison.

Agree Beau
Beau,

I think you've hit the nail on the head about the problem not being the testing but the handling of the test results. Interestingly, Dr. Brawley's biography, quoted from the ACS website says in part: "As the chief medical officer and executive vice president of the American Cancer Society, Otis Webb Brawley, MD, is responsible for promoting the goals of cancer prevention, early detection, and quality treatment through cancer research and education. He champions efforts to decrease smoking, improve diet, detect cancer at the earliest stage, and provide the critical support cancer patients need. He also guides efforts to enhance and focus the research program, upgrade the Society’s advocacy capacity, and concentrate community cancer control efforts in areas where they will be most effective. Further, as an acknowledged global leader in the field of health disparities research, Dr. Brawley is a key leader in the Society’s work to eliminate disparities in access to quality cancer care."

It seems somewhat disingeneuous to me that a doctor responsible for championing the detection of cancer at the earliest stage would take such a critical stand against PSA testing. While many men may be over treated, I agree with you that the dangers lie in how doctors handle the information of PSA to their patients and take subsequent actions that may result in over treatment.

In my opinion, the good doctor should be looking for a better way to counsel GPs and urologists on how PSA scores should be interpreted for their patients, how to rule out other things that could be causing the PSA such as BPH, prostititus, UTI, etc., and quit doing bone scans for newly diagnosed low risk patients.

K

hunter49

Great analysis. I agree
Great analysis. I agree that the treatment is the issue not the screening. I met someone recently who is 65 and was diagnosed after his first ever PSA test. his number of 4.3 called for a biopsy. # of 14 cancer less than 25% and no PNI. Worse he was a 3+3. What I would consider active surveilance. His DRE was negative. His urologist insisted he have surgery and worse yet it was at a teaching hospital. HE WAS NEVER GIVEN ANOTHER OPTION. 5 months later still has incontinence and ED. He was in great shape no symptoms and is literally suicidal. Problem I agree is what we do with the results

hunter49

Great analysis. I agree
Great analysis. I agree that the treatment is the issue not the screening. I met someone recently who is 65 and was diagnosed after his first ever PSA test. his number of 4.3 called for a biopsy. # of 14 cancer less than 25% and no PNI. Worse he was a 3+3. What I would consider active surveilance. His DRE was negative. His urologist insisted he have surgery and worse yet it was at a teaching hospital. HE WAS NEVER GIVEN ANOTHER OPTION. 5 months later still has incontinence and ED. He was in great shape no symptoms and is literally suicidal. Problem I agree is what we do with the results

Beau2

Kongo said:

Agree Beau
Beau,

I think you've hit the nail on the head about the problem not being the testing but the handling of the test results. Interestingly, Dr. Brawley's biography, quoted from the ACS website says in part: "As the chief medical officer and executive vice president of the American Cancer Society, Otis Webb Brawley, MD, is responsible for promoting the goals of cancer prevention, early detection, and quality treatment through cancer research and education. He champions efforts to decrease smoking, improve diet, detect cancer at the earliest stage, and provide the critical support cancer patients need. He also guides efforts to enhance and focus the research program, upgrade the Society’s advocacy capacity, and concentrate community cancer control efforts in areas where they will be most effective. Further, as an acknowledged global leader in the field of health disparities research, Dr. Brawley is a key leader in the Society’s work to eliminate disparities in access to quality cancer care."

It seems somewhat disingeneuous to me that a doctor responsible for championing the detection of cancer at the earliest stage would take such a critical stand against PSA testing. While many men may be over treated, I agree with you that the dangers lie in how doctors handle the information of PSA to their patients and take subsequent actions that may result in over treatment.

In my opinion, the good doctor should be looking for a better way to counsel GPs and urologists on how PSA scores should be interpreted for their patients, how to rule out other things that could be causing the PSA such as BPH, prostititus, UTI, etc., and quit doing bone scans for newly diagnosed low risk patients.

K

He's Shooting the Messenger (PSA)
Kongo,
I agree that Dr. Brawley should be looking at better ways to counsel GPs and urologists. To your excellent list of topics to be covered I would like to add that he consider advising that low risk (G6, etc. etc.) patients be advised to consider AS. To me this is the conclusion that should be drawn from the research he cites (i.e. Too many low risk patients are being treated); not that PSA testing should be discontinued.

I am guessing that he can not recommend that low risk cancer patients follow AS (and not be treated) because many patients that are initally thought to be low risk aren't; therefore, it is more convient to conclude that the early testing leads to too many side effects from treatment. By doing this, I feel he is giving up on early diagnosis of PCa patients and deciding 30,000 deaths (in the USA) from PCa is a number he can live with.

msjpd,
I agree and have made the contacts you suggest; however, based on Dr. Brawley's published opinions supporting the panel, I am beginning to believe that the horse has already left the barn and that no changes will be made to the original recommendations ... after all the American Cancer Society supports the recommendations. Does Dr. Brawley speak for the American Cancer Socety?

hopeful and optimistic

hunter49 said:

Great analysis. I agree
Great analysis. I agree that the treatment is the issue not the screening. I met someone recently who is 65 and was diagnosed after his first ever PSA test. his number of 4.3 called for a biopsy. # of 14 cancer less than 25% and no PNI. Worse he was a 3+3. What I would consider active surveilance. His DRE was negative. His urologist insisted he have surgery and worse yet it was at a teaching hospital. HE WAS NEVER GIVEN ANOTHER OPTION. 5 months later still has incontinence and ED. He was in great shape no symptoms and is literally suicidal. Problem I agree is what we do with the results

Draft to eliminate PSA tests to determine prostate cancer
In my opinion this draft is F____ing UNBELIEVABLE.

The PSA test is a simple indicator blood test that shows if a biopsy may be needed to determine if cancer exists. The PSA and Biopsy are valid tests and very useful. The problem is not with the PSA or the biopsy but with educating or changing how things are done after diagnosis, so that overtreatment will not be performed as a result of uncertainty, fears, ignorance and the need to do “something”. If this can be done there would be no discussion about the PSA test, a valid tool.

Many men will die if this diagnosis PSA test is eliminated. Previous to the PSA test, over 42k men died from the disease, currently, with the test in use for diagnosis with an aging population in the USA, about 32K die a year, a reduced amount, but still too high.

There are several circumstances where the PSA test is required in order to save lives

Men die, with many in a very poor way when the disease is diagnosed at an advanced stage instead of earlier detection.(I met a couple at support groups where their doc did not do a PSA or digital rectal exam, and then showed symtoms later on and are now dying.)

Even for those who are diagnosed at an early stage as I have been, 30 percent of us require active treatment as a result of cancer progression. The doctors tell us that we should be closely monitored so they could tell who it will be. So, if I and others like me were not diagnosed with early stage prostate cancer, 30 percent of us will have disease progression without treatment. I wonder how many men this would affect, and how many will die or be debilitated from the disease?
(WTF, the next thing that you might hear from this board is that those on Active Surveillance should not be monitored because of the cost, to help the economy.)

I and other men simply want to be diagnosed, treated and to stay alive as any normal person would like. Is that asking too much????

VascodaGama

hopeful and optimistic said:

Draft to eliminate PSA tests to determine prostate cancer
In my opinion this draft is F____ing UNBELIEVABLE.

The PSA test is a simple indicator blood test that shows if a biopsy may be needed to determine if cancer exists. The PSA and Biopsy are valid tests and very useful. The problem is not with the PSA or the biopsy but with educating or changing how things are done after diagnosis, so that overtreatment will not be performed as a result of uncertainty, fears, ignorance and the need to do “something”. If this can be done there would be no discussion about the PSA test, a valid tool.

Many men will die if this diagnosis PSA test is eliminated. Previous to the PSA test, over 42k men died from the disease, currently, with the test in use for diagnosis with an aging population in the USA, about 32K die a year, a reduced amount, but still too high.

There are several circumstances where the PSA test is required in order to save lives

Men die, with many in a very poor way when the disease is diagnosed at an advanced stage instead of earlier detection.(I met a couple at support groups where their doc did not do a PSA or digital rectal exam, and then showed symtoms later on and are now dying.)

Even for those who are diagnosed at an early stage as I have been, 30 percent of us require active treatment as a result of cancer progression. The doctors tell us that we should be closely monitored so they could tell who it will be. So, if I and others like me were not diagnosed with early stage prostate cancer, 30 percent of us will have disease progression without treatment. I wonder how many men this would affect, and how many will die or be debilitated from the disease?
(WTF, the next thing that you might hear from this board is that those on Active Surveillance should not be monitored because of the cost, to help the economy.)

I and other men simply want to be diagnosed, treated and to stay alive as any normal person would like. Is that asking too much????

What about DRE. Why
What about DRE. Why shouldn't they include that too?
It is as bad when “finding” (screening) cancer and diagnosing for a “diaper’s” induced treatment.
There are a lot of misunderstandings in what a PSA can do. The majority of doctors do not even know what cancer symptoms are. Ignorance is evident in all corners of this draft, by the ones that have even drawn it up.

Scrap all treatments and you find the savings, Mr. Brawley.

mrspjd

Beau2 said:

He's Shooting the Messenger (PSA)
Kongo,
I agree that Dr. Brawley should be looking at better ways to counsel GPs and urologists. To your excellent list of topics to be covered I would like to add that he consider advising that low risk (G6, etc. etc.) patients be advised to consider AS. To me this is the conclusion that should be drawn from the research he cites (i.e. Too many low risk patients are being treated); not that PSA testing should be discontinued.

I am guessing that he can not recommend that low risk cancer patients follow AS (and not be treated) because many patients that are initally thought to be low risk aren't; therefore, it is more convient to conclude that the early testing leads to too many side effects from treatment. By doing this, I feel he is giving up on early diagnosis of PCa patients and deciding 30,000 deaths (in the USA) from PCa is a number he can live with.

msjpd,
I agree and have made the contacts you suggest; however, based on Dr. Brawley's published opinions supporting the panel, I am beginning to believe that the horse has already left the barn and that no changes will be made to the original recommendations ... after all the American Cancer Society supports the recommendations. Does Dr. Brawley speak for the American Cancer Socety?

Has the horse left the barn?
Beau,

Your comments are very perceptive. It’s anyone’s guess if the horse has left the barn on this one and if a reversal or any revisions will be considered and/or included by the Task Force in their final recommendation document (IMO, saving face is, unfortunately, a big deal for those professionals.)

IMO, if history is any indication of future prediction, one only has to examine the Task Force’s recent controversial final recommendation re mammography screenings for breast cancer in women and the subsequent statement by Kathleen Sebelius, Secretary, U.S. Health and Human Services, to stay the existing course for mammogram screening guidelines.
http://www.hhs.gov/news/press/2009pres/11/20091118a.html

Many believe that Secretary Sebelius’ statement on Breast Cancer recommendations was due, in part, to the effort of the Breast Cancer community to mount a successful media and outreach campaign that made the difference. Not only did that campaign include an effort to encourage everyone to submit comments to the task force during the public comment period but, it also urged them to write to Secretary Sebelius, as well as to their Congressional representatives voicing opposition to the USPSTF recommendations against early detection screenings for Breast Cancer.

Right now, the collective “voice” and outrage of the PCa community needs to be heard loud and clear by the Task Force AND by our politicians, too, if we are to affect change and make a difference as was the case re mammogram screening guidelines for Breast Cancer. It cannot be over emphasized: Submit your comments to the USPSTF. U.S. residents are urged to write letters to their Congressional representatives and Secretary Sebelius. Ask your friends to do the same.

The draft document is recommending against PSA based early detection screening for PCa in asymptomatic men and the Task Force has assigned a D rating to the test. The D rating indicates the following determination: “The USPSTF recommends against the service [PSA screening]. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. Discourage the use of this service.” This rating may impact how some medical insurance providers may view PSA screening as not indicated, and a non-covered expense.

IMO, if the Breast Cancer community can mount a successful campaign re recommendations for mammogram screenings, then the PCa community must do the same for PSA based screenings for PCa. The hope is that the PCa community (medical professionals, patients, men and women) will mobilize to provide sufficient public comment/evidence/outrage to make a difference.

mrs pjd

mrspjd

Kongo said:

Agree Beau
Beau,

I think you've hit the nail on the head about the problem not being the testing but the handling of the test results. Interestingly, Dr. Brawley's biography, quoted from the ACS website says in part: "As the chief medical officer and executive vice president of the American Cancer Society, Otis Webb Brawley, MD, is responsible for promoting the goals of cancer prevention, early detection, and quality treatment through cancer research and education. He champions efforts to decrease smoking, improve diet, detect cancer at the earliest stage, and provide the critical support cancer patients need. He also guides efforts to enhance and focus the research program, upgrade the Society’s advocacy capacity, and concentrate community cancer control efforts in areas where they will be most effective. Further, as an acknowledged global leader in the field of health disparities research, Dr. Brawley is a key leader in the Society’s work to eliminate disparities in access to quality cancer care."

It seems somewhat disingeneuous to me that a doctor responsible for championing the detection of cancer at the earliest stage would take such a critical stand against PSA testing. While many men may be over treated, I agree with you that the dangers lie in how doctors handle the information of PSA to their patients and take subsequent actions that may result in over treatment.

In my opinion, the good doctor should be looking for a better way to counsel GPs and urologists on how PSA scores should be interpreted for their patients, how to rule out other things that could be causing the PSA such as BPH, prostititus, UTI, etc., and quit doing bone scans for newly diagnosed low risk patients.

K

Double Standard
Dr. Brawley states: “The Task Force review does see SOME benefit to prostate cancer diagnosis and treatment.” No doubt Dr. B concludes, as does the Task Force, that “SOME” of the benefit for PSA testing is:

(1) only for men presenting with symptoms, when PSA testing may detect a more advanced, often metastatic, PCa stage, and therefore, be more difficult & co$tly to treat, both physically and mentally; and

(2) after PCa treatment, when PSA testing is the primary blood test utilized for detecting rising Prostate-Specific Antigens (PSA), in other words, for detecting recurrence of PCa following treatment, including active surveillance (AS) tx, which is considered a “treatment” option.

How can the same PSA test that has no value in screening asymptomatic men for PCa, as Brawley and the USPSTF have deduced, have value in the management of PCa after treatment or during AS by detecting (rising) PSA for evidence of the same disease and/or PCa recurrence? The irony is that there is no AS without first screening asymptomatic men with PSA testing. Double standard. Fuzzy logic.

Until better and more reliable tests become available, PSA tests for PCa screening for asymptomatic men are the best we have right now. PSA testing may not be perfect, may be flawed, but IMO, don’t discard an inexpensive test that saves lives by making recommendations to throw the baby out with the bath water. Affect change by establishing standardized proactive PCa educational guidelines for PCa patients AND medical professionals so men can make informed educated choices.

Outraged or not, please consider submitting your comments to the USPSTF on their website @ http://www.uspreventiveservicestaskforce.org/tfcomment.htm before Nov. 8 when their public comment session closes. To learn more about the USPSTF’s controversial draft recommendation against PSA based screening, follow this CSN link: http://csn.cancer.org/node/228042

Want to do more? Email/write letters to your Congressional representatives @: www.congress.org and ALSO to Kathleen Sebelius, Secretary, U.S. Health and Human Services, urging them to stay the course for offering PSA screening for PCa to informed asymptomatic men.

mrs pjd

Beau2

Steve Forbes' Take on PSA
I had not known that Steve Forbes was a PCa survivor. Appears he took the PSA issue to heart and published his opinion in the November issue of Forbes magazine. Just so you get a feel for what side he is coming down on he refers to the USPSTF as The Department of Health and Human Services Death Panel.

The article can be read at:
http://www.forbes.com/sites/steveforbes/2011/11/03/the-department-of-health-and-human-services-death-panel/

mrspjd

Beau2 said:

Steve Forbes' Take on PSA
I had not known that Steve Forbes was a PCa survivor. Appears he took the PSA issue to heart and published his opinion in the November issue of Forbes magazine. Just so you get a feel for what side he is coming down on he refers to the USPSTF as The Department of Health and Human Services Death Panel.

The article can be read at:
http://www.forbes.com/sites/steveforbes/2011/11/03/the-department-of-health-and-human-services-death-panel/

show of support
Hey Beau,

Great article by Forbes. Thanks for posting the link. As Forbes indicates, it’s a sad reality that this is more about a political/economic issue than about an earnest concern for men's health and well being. All the more reason for guys and gals (PCa "bros and sistas") to take the time to send letters to their U.S. government representatives voicing opposition to the USPSTF recommendation.

Also, thanks for your (and Vasco’s) posts & show of support on the “Call to Action” thread. While PCa is a cancer that strikes only men, many often forget that the PCa community is co-ed. We, the women, are the wives, mothers, daughters, sisters, family and friends of men diagnosed with PCa. And we, men and women, are all in this battle together, with many on the front lines, and others, as the support network.

mrs pjd

P.S. Unsure, but I seem to recall in 2009, when Dr. Brawley (on behalf of the ACS) supported the USPSTF recommendations for changing the mammogram screening guidelines for breast cancer, there was a petition ciculating that called for Dr. B's removal from the ACS. Wonder if that petition is still out there?