AAFP Recommends Against DREs For Prostate Cancer Screening

As a prostate cancer survivor, having undergone a robot assisted laparoscopic prostatectomy in 2013, I’ve developed a certain sensitivity and concern regarding the subject of screening for prostate cancer. I do agree that PSA testing has been over utilized as a screening technique. I have read Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement and their recommendation against PSA-based screening for prostate cancer. I understand their rationale.

On September 24, 2013, AAFP released "American Academy of Family Physicians Releases Third Choosing Wisely® List, Identifies Five Medical Procedures Doctors Should Question".

“As primary care specialists, family physicians are the frontline providers for millions of Americans – so we have a duty to make sure our members are doing everything they can to provide the right care, for the right patient, at the right time,” said Reid Blackwelder, MD, FAAFP, president of the AAFP. “In today’s healthcare environment, it is increasingly important to ensure physicians deliver the most effective, beneficial care possible. These Choosing Wisely lists can help our members identify treatments and procedures that may be wasteful.”

The third recommendation of the five was the following:

3. Do not routinely screen for prostate cancer using a prostate-specific antigen (PSA) test or digital rectal exam.
There is convincing evidence that PSA-based screening leads to substantial over-diagnosis of prostate tumors. Many tumors will not harm patients, while the risks of treatment are significant. Physicians should not offer or order PSA screening unless they are prepared to engage in shared decision making that enables an informed choice by patients.

On the AAFP website, sources for this recommendation always point back to the U.S Preventive Services Task Force and their recommendation against PSA-based screening for prostate cancer.

While I understand the basis for your recommendation to family physicians to not routinely screen for prostate cancer using a PSA test, I do not understand the basis for your organization’s further recommendation to not routinely screen for prostate cancer using a digital rectal exam.

The U.S Preventive Services Task Force made no such recommendation regarding digital rectal exams. I have been unable to find any organization other than AFFP who recommends against digital rectal exams. I have scoured the literature and can find no such conclusions in any studies as well.

So on what basis did AFFP choose to add digital rectal exams to their recommendation to not routinely screen for prostate cancer using PSA?

There have been numerous published studies over the past 20 years on the significant value that digital rectal exams provide when a nodule or similar abnormality is felt on a patient’s prostate. Are patients to now lose access to such a simple in-office yearly procedure from the primary care physicians on whom they depend upon?

I believe the American Academy of Family Physicians should provide reasonable justification for this recommendation against performing digital rectal exams or strike "digital rectal exams" from that specific recommendation entirely.




I posted this topic to Healingwell and shortly thereafter I sent it as an email to the American Academy of Family Physicians for comment. The following is their response which I think is outrageous. What do you think?

Thank you for reaching out to us about our Choosing Wisely recommendation concerning prostate cancer screening. The digital rectal exam is known to have a low positive predictive value and high inter-examiner variability. It only detects prostate cancer if it is palpable, which means the majority of cancers that are detected by DRE are already advanced and many of these patients already have symptoms. PSA testing was added to the DRE to improve its predictive value, and most of the available studies use either PSA alone or in combination with DRE. In the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, individuals that had a PSA and DRE did not have any reduction in morbidity and mortality. The USPSTF's recommendation against PSA-based screening was based on this study as well as other studies of PSA alone or in combination with DRE. You are right that the USPSTF did not specifically recommend against the digital rectal exam (although they also didn't recommend FOR it), but the AAFP feels that this should have been addressed so we took that extra step.

I am glad that your prostate cancer was detected and hope that your treatment was a success. I understand your sensitivity to the topic and appreciate the opportunity to explain our recommendation.

Sincerely,


Jennifer L. Frost, MD, FAAFP│ Medical Director
Health of the Public and Science
American Academy of Family Physicians
11400 Tomahawk Creek Parkway │ Leawood, KS 66211
Office: (913) 906-6000, ext. 3100
jfrost@aafp.org

Randyjoe

While I did say that I understood their rationale regarding not recommending the PSA test, I can't say I fully agree with it. It's such a balancing act with no guarantees whatsoever. In my case, my PSA results were a "false negative". PSA results obviously also produce a lot of "false positives". Are we to bury our heads in the sand and not submit to a PSA test? Without the abnormal DRE, I'd have never gone for the biopsy. There's the macro level and the micro level. They are on the "macro" level "big picture" and we're on the "micro" level, just trying to keep living a reasonable life. We can only do the best we can and remember that behind all the numbers, there are guys just like us!

halbert

You are absolutely right. The answer is better screening which however seems to be somewhat of a moving target. What I am afraid of, especially like when an organization like the AAFP says no to digital rectal exams, is that they're looking for perfection which they will never find. If THEY keep moving the bar on what constitutes effective screening, what do all guys do in the meantime. As you said, do we go back to the "old days", like in the late 70s when my dad wasn't diagnosed for Pca until it was in his bones? And then he lasted less than 12 months?

Wow. So no PSA test, and no DRE. So, no attempt whatsoever at early detection? They have got to be kidding.

Yes, that's back to the really old days, like the 1920s or earlier. 1800s? So the only guys that would go to a uro for a problem would be in a very serious situation, due to bone pain or inability to urinate. Holy moley.

My cynical self says yes, follow the money. It's expensive for insurance to cover PCa treatments. On the other hand, let it become rampantly metastatic and severely advanced, they'll decide that an inexpensive medical intervention (orchiectomy) and some cheap painkillers are all that's necessary. Voila, they eliminate a great amount of risk!

Appalling.

I agree wholeheartedly with Halbert, well put and absolutly right. I would not be alive today, except for PSA screening and DREs.

The AAFP can kiss my arse!!or prostate whatever they prefer!

I posted this topic to Healingwell this morning after I sent it as an email to the American Academy of Family Physicians for comment. The following is their response which I think is outrageous. What do you think?

Thank you for reaching out to us about our Choosing Wisely recommendation concerning prostate cancer screening. The digital rectal exam is known to have a low positive predictive value and high inter-examiner variability. It only detects prostate cancer if it is palpable, which means the majority of cancers that are detected by DRE are already advanced and many of these patients already have symptoms. PSA testing was added to the DRE to improve its predictive value, and most of the available studies use either PSA alone or in combination with DRE. In the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, individuals that had a PSA and DRE did not have any reduction in morbidity and mortality. The USPSTF's recommendation against PSA-based screening was based on this study as well as other studies of PSA alone or in combination with DRE. You are right that the USPSTF did not specifically recommend against the digital rectal exam (although they also didn't recommend FOR it), but the AAFP feels that this should have been addressed so we took that extra step.

I am glad that your prostate cancer was detected and hope that your treatment was a success. I understand your sensitivity to the topic and appreciate the opportunity to explain our recommendation.

Sincerely,


Jennifer L. Frost, MD, FAAFP│ Medical Director
Health of the Public and Science
American Academy of Family Physicians
11400 Tomahawk Creek Parkway │ Leawood, KS 66211
Office: (913) 906-6000, ext. 3100
jfrost@aafp.org

This reminds me several years ago when the medical industry came out and stated routine mammograms should be recommended. I have several friends that would not be alive today if it wasn't for routine mammograms. Prostate cancer, colon cancer, skin cancers are in the same boat. It has been stated that one third of the "older" population will get cancer sometime in their life, and for the "younger" population the they on in two will get cancer.

I do see the difference between the macro and micro perspective of the economics aspects of cancer. But when you or your love one gets cancer, then the chance of recovery is very heavily dependent on early diagnosis.

clanda said...
testing 1123

I took a look at the NCCN guidelines and then looked further at the referenced studies. What NCCN refers to as men with normal PSA, the referenced study states that their "normal" is less than 2.9. They then go on to further state that when you get above a PSA of 3: "The situation changes drastically in those men whose PSA values are greater than or equal to 3.0 ng/mL. "

But if you are screening, a PSA >3 gets you past screening. The NCCN now uses >3 for further workup (page PROSD-3).

John T said...
There is no difference in surviveability or outcomes, so what are we getting for the extra 2.3 trillion dollars we are spending?

Healthcare and tech have been the best performing stock sectors recently.

Thank you, RCS. Exactly what I've been thinking as well. There is a common idea expressed in these reports and recommendations that seems to be echoed in this space. And that is, that a biopsy is an unnecessary highly risky thing. Facts, please. The risks involved in biopsy are these: One risk is of infection or other medical issues. These do occur, but they are vanishingly rare. Same with side effects like incontinence and ED. Really, Really rare. The other risks are inherent in any biopsy: (a) that it will find nothing when something is there or (b) that it will find something that looks much worse than it really is.

Two sides of the same coin. It is still, however, the best tool we have commonly available. There are new things coming along, MRI guided biopsy, saturation transperineal biopsy, etc. I truly believe that the day will be here, probably within a very few years, where a skilled pathologist will be able to look at a test series and biopsy and be able to say to individual patients, "YOU sir, have indolent cancer and need do nothing, ever", while also saying to another individual, "I'm sorry, sir, but you've got it, and it's the aggressive nasty kind, and you'll need to have treatment." When THAT happens, the overtreatment argument will end once and for all.

If the US really wants to cut medical expenses it should get serious about busting the fraud and rampant crime that are now part and parcel of the system here.

My radiation oncologist' office was right next door to Dr Fata's office. You all likely saw it on the tv news. He got more than $17 million through fraud and mistreatment/misdiagnosis. That was a lot more than my smelly little PSA test and DRE cost. Gratefully, my physician had disregarded the govt's directive to cease PSA testing.

I would far rather be 'over-treated' and cured of PCa than under-treated and die from it.

I'm a bit surprised that I did not find much support here for Digital Rectal Exams. Do most of you really feel that their routine use should be curtailed? While they're not fun, if the Dr picks up on an abnormality such as a nodule, wouldn't you want to know about it? There would be a fairly high percentage of them that are Pca, with or without a corresponding PSA test.

clanda, I think the general, but not universal, consensus among those of us here is that screening by PSA and DRE, followed by biopsy if there is something suspicious is vitally important and these recommendations are heard to be saying "PSA is worthless and PC screening is pointless", without further reading or discussion of what the rest of it all says.

I'm one who insisted on screening starting at age 40 due to family history, and was totally unsurprised when things started changing. And, I'm also one who had a G6 biopsy on one side, and G7 in all 4 quadrants after surgery. So, in my case I don't believe I was over-treated.