HealingWell
Search Close Search
☰

Urology group stops recommending routine PSA test

Support Forums
>
Prostate Cancer
✚ New Topic ✚ Reply
1 2 3 45 6 7 8
❬ ❬ Previous Thread |Next Thread ❭ ❭
Posted 5/5/2013 10:51 AM (GMT -5)
We are quick to attribute a drop in mortality entirely to psa testing. PC mortality had been dropping well before the advent of large scale psa testing. The incidence of PC also declined an average of 1.9% per year from 2000 to 2009 in the years of heavy psa testing when we would expect it to increase substantially. Mortality decreased by 3.5% annually during this same period. 54% of the mortality reduction is due to the reduction in the incidence rate of PC.
Unquestionably psa testing has had an effect on mortality, but it is nowhere in the range of 40%. The reduction in the rate of total incidences and treatments for advanced PC that extend lives are the most probable cause of the majority of the mortality reduction.
Posted 5/5/2013 12:20 PM (GMT -5)
Jerry asked "Do you agree that more men will progress to the advanced stages with the new recommendations?"

It could Jerry, but I don't see it any worse than when the PSA testing was 50yo/45yo for high risk. We're actually affording the opportunity to find it earlier than that with the stratification they way it is with these new guidelines. We have since 2009 had a new protocol that said baseline at 40/35. That has never been the norm before 2009 and we many never know what impact it had disease progressions or prostate cancer specific mortality. Seeing as how guys like you and I represented the 0.05% I doubt it had much impact at all on the overall statistics.

Tony
Posted 5/5/2013 12:20 PM (GMT -5)
tony, thanks for answering, and of course I respect your opinion, especially with your level of involvement, but your answer - ethics, however noble that sounds, is still problematic for me to buy into.

I would like to think that is the case, but I still find the whole thrust of this limiting of testing argument not in the best interest of men' s health.

Why not come up with better determinations of how and when to treat PC found, as opposed to limiting men to testing? If overtreatment is the real issue, then that should be the area of focus.

david in sc
Posted 5/5/2013 12:23 PM (GMT -5)
tdmjam said "Thank God these morons weren't campaigning against PSA testing 8 years ago"

These "morons" are not against testing in these recommendations either. It's the USPSTF that is against it. The AUA is trying to provide better evidence based testing so that our PCP's know when to screen. As it is right now the PCP's could listen to the USPSTF and send you home rather than scree, or they can read these AUA guidelines and stratify a patient for the examination.

Tony
Posted 5/5/2013 12:26 PM (GMT -5)
As far as the Samadi video...

It has nothing to do with the AUA guidelines and is a video about the USPSTF. Samadi is a member of the AUA that released these new guidelines.

Tony

Post Edited (TC-LasVegas) : 5/5/2013 11:41:45 AM (GMT-6)

Posted 5/5/2013 12:33 PM (GMT -5)
Thanks Tony.

I personally and strongly believe it will and I think it is unethical to let that happen. 

Posted 5/5/2013 12:42 PM (GMT -5)
Jerry,
Do you believe that the guidelines from the AUA this weekend were better or worse than the guidelines from pre-2009?

Tony
Posted 5/5/2013 1:52 PM (GMT -5)
Tony,

The new guidelines are better than the ones before 2009. My problem is not just with these new guidelines and I haven't completely put my finger on the complete issue. This ongoing trend toward the USPTF giudelines by these reputable assoiciations is troubling. Something just isn't adding up for me. It's like they care more about a portion of guys getting over treated vs. a much smaller subsection of guys dealing with advanced disease and death. There has to be a better solution.

I am not upset at you. You are the messenger and you do great things all things PC. I am upset at this whole thing though, and someday I will figure out why.

Thanks,
Jerry
Posted 5/5/2013 2:07 PM (GMT -5)
This is a really interesting thread for me.  The two guys on this forum for whom I have the most respect - JohnT and TonyC - are joined together in a position that I'm having a hard time embracing.  And, I find that davidg, who I used to fight with a lot, has a position that more closely resembles my own.  Boy -- ain't life strange?

First of all, just to clear the air, I do agree with Tony that the video by Dr. Samadi has nothing to do with the new AUA guidelines...any references to "no urologists" on the panel are certainly not related to the new guidelines which are indeed put together by urologists.  It will also be very interesting how Dr. Samadi and other high-volume, respected surgeons react to the new guidelines.

Also, I agree that there is an epidemic of overtreatment.  We even still see it on this forum as early stage, low volume cancer patients jump into surgery with lots of encouragement from other forum members.  So, I suppose that these new guidelines are the inevitable result of out-of-control patients and their doctors who insist on treatment at the slightest hint of cancer.

However, I still find myself believing that the epidemic is overtreatment and not over-diagnosis.  I understand that diagnosis leads to treatment and, many times, over treatment.  But I still have trouble coming to grips with the concept that knowledge of one's cancer is bad.  I think I would have been happier with a statement that included routine screening but provided guidelines for treatment that could be embraced by the AUA.  Something like, recommending AS for patients with G6 and specific treatment recommendations for other G scores, core numbers and cancer percentages.  Something like recommended tests before biopsy.  Something like added tests (e.g. Prostyvision) after biopsy.  Something like the appropriate number of cores to sample (not 6!!!) based on prostate size.  Something like a list of certified labs that know how to properly read a PCa slide.

No, I really think that the AUA took the easy way out.  Their new guidelines certainly will improve the level of overtreatment.  But...they could have done so much better that I'm still disappointed.  Perhaps I will come around and get enlightened on this but, for now, I'm having trouble getting my arms around a proposal that I find severely lacking.

Jim

Posted 5/5/2013 2:21 PM (GMT -5)
Jim, I was waiting for you to jump in on this one, glad you did. you and I are on the same page, just different verbiage. if the problem is overtreatment, then deal with overtreatment, there are all kinds of things that could be done to slow down and correct that side of the problem. but on the screening side, it still seems irresponsible at best, what is being recommended.

david
Posted 5/5/2013 3:19 PM (GMT -5)
If anyone here were attributing the reduction in PCa entirely on PSA testing that would be wrong. Some action is needed after the cancer is present to alter the course of the disease. On the other hand it is also wrong to say that the entire problem of PSA testing is over diagnosis and over treatment when there is no real life evidence that the over treatment rate is in the 70% range. Under treatment is equally ignored…

If we cannot agree that the SEER published figures report a 40% decrease in the PCa mortality rate between the peak mortality in 1993 and 2007 then why even discuss the issue and just provide a bunch of numbers without reference to negate the published numbers.
See the SEER database figures at:

seer.cancer.gov/csr/1975_2007/browse_csr.php?section=23&page=sect_23_table.06.html
There you can see that the mortality rate has been reduced by 40%

John T, can you explain how “54% of the mortality reduction is due to the reduction in the incidence rate of PC.” is possible?
Please show us where the numbers come from.

The rate of over treatment reported is a calculated number obtained from computer models based on definitions. A real life result based on the Tyrol study yielded 8.75 to 17% rate of over treatment. This after every patient diagnosed with PCa were treated in some form. Those discrediting the value of PSA testing in reducing mortality have ignored this unique study.
link.springer.com/article/10.1007/s00038-011-0266-4/fulltext.html

RalphV
Posted 5/5/2013 3:47 PM (GMT -5)
Tud,
Just to clarify my position; I'm not against screening per say, only mass screening of an entire population. Any one who wishes to be screened can still do so, just so he is aware if it before hand and gives his permission. My kids will get screened at 40 as they are in a higher risk category. Anyone with exposure to chemicals like Agent Orange or African Americans or those employed as farmers or pilots who are higher risk should also get screened. A healthily 75 year old should not. We just have to be smarter in who we screen. Getting a yearly psa test at your annual physical is not necessary. They stopped giving chest X-rays as a normal part of annual physicals a couple of years ago because it didn't make a difference in surviving lung cancer.
I also think that these guidelines will still continue to change as they have over the past few years as more data comes in. I realize that this is a hard topic because we are all emotionally involved in this disease. I'll let the data guide my opinion and when it changes I'll change my thinking.
Unfortunately over treatment and screening are linked at this current point in time. We can say that over treatment is the real issue, but there is no easy way to separate these two issues because of the emotional reaction to a cancer diagnosis.
We also need a better method or guidelines determining when to biopsy as currently a high PSA normally triggers an automatic biopsy. If we had better biopsy and better treatment triggers I would be much more receptive to wider psa screening. Right now I think the harm out weighs the benefits. I totally understand that reasonable individuals will hold a much different viewpoint.
JT
Posted 5/5/2013 4:03 PM (GMT -5)
David,
I understand your position about every life being important. If we reduced the maximum speed limit to 40 mph we would save thousands of lives a year, but it comes at a cost of time and inconvenience. Just as if we screen every individual we would definitely save lives, but we also must consider the other side of the equation.
We set low speed limits on the riskiest parts of the roads and don't treat all roads the same; it's a balanced approach just like we need to balance the benefits and harms of screening. We should not screen zero, nor should we screen 100%. I think the discussion is where to set that line so it gives the greatest overall benefit and I think the current guidelines are a reasonable place.
JT
Posted 5/5/2013 4:55 PM (GMT -5)
John T --- good analogy with the speed limit. The USPTF must have no speed limit in that analogy.

Tony --- I think one of my first problems is when the USPTF came out with their guidelines, there was a stir, but then settled down. Why is it that few people found it outrageous enough to try to get it changed. I saw only a handful try to get a message to them to change it (unlike with BC when they said mammagrams should start when a woman is 50.)

Why didn't groups of patients and/or other entities fight back? Why didn't these associations that know better say and do more?

Jerry
Posted 5/5/2013 5:01 PM (GMT -5)
JohnT

For starters, 100% of men will never be screened, this has never happened nor is it reasonable to expect so. I know too men that choose to remain ignorant on their personal health. The "I will never go to the doctor or go to a hospital" mentality. Nor do I see anyone here advocating 100% of men to be screened.

The old standards still work for me. Get a base line test at age 50. Start that baseline earlier if you have family history, or if you are African-American. I see nothing wrong with those standards, its reasonable.

And for all those in this thread that are agreeing with Tony on these "new standards", not a one of them can explain how it would help overtreatment. By denying men the knowledge that they have cancer, well, of course they will never be treated, because they simply don't know. Sure many of them won't have cancer, many others will have indolent cancer, but in that same untested group, there will be many men with serious cancer, whom ultimately will be coming for treatment in an advanced state, or worse.
So how does that scenario help "men's health"?

I keep coming back to my same thought - deal with the overtreatment issue separately. Don't automatically allow men to have surgery or radiation that don't need it, push harder for AS in those cases, that would slow down overtreatment in a hurry, if men not needing treatment - simply couldn't get it just because they want to, or if its just a fear based answer. No doctor is going to agree to cut off a guy's foot, just because he has an infected in-grown toe nail, that could get worse, and could get gangrenous over time. Absurd -yes, but trying to make a point.

david
Posted 5/5/2013 5:38 PM (GMT -5)
What's being overlooked in the many well-intentioned attempts here at HW to find a balanced and nuanced approach to testing and treatment is that the large majority of men in the general population who are not involved with PCa in a personal way will never become aware of any of the nuances and balances. Instead, we all know that the takeaways of the average guy from his fleeting exposure to the recent rounds of publicity regarding PCa will be something like this:

1) "Screening not recommended"="I don't ever have to bother getting THAT test."

2) "For every 1,000 persons treated, only 1 life is saved"="Even getting treated doesn't make any difference, so why pay any attention at all to it?"

Guys don't need any encouragement to avoid doctors and tests. I guarantee you that millions of men hearing or reading the sound bites coming out of the recent rounds of recommendations will remember only this--"Prostate cancer: forget about it!"
Posted 5/5/2013 5:44 PM (GMT -5)
Tony,

Back when I was a kid, it was quite common to have a friend that had a Tonsillectomy. By today's standards, I think it is clear that there were likely many cases of over diagnosis and surgical treatment of those with sore throats and limited infections. The solution to over treatment however wasn't to tell the doctors to stop looking in a child’s mouth, or swabbing for an infection; because you might find something wrong and over-treat the child. Rather, the medical community adjusted the “treatment” protocols. Even as late as last year the American Academy of Otolaryngology-Head and Neck Surgery Foundation provided additional detailed recommendations for when surgical “treatment” of this condition is appropriate.

In my opinion it would have been much more responsible and ethical for the AUA brain trust to focus their energies on new “treatment” guidelines, as many other have suggested here.

This may not be the best medical comparison, but can you explain what the reasons were that they did not focus their recommendations on the treatment aspects instead?

News headlines stating that the AUA recommends tougher guidelines for prostate cancer biopsies and treatments could have been very effective at getting the message out about over treatments.

Maybe it goes without saying, but I assume the screening recommendation includes DRE's? They do go hand in hand with PSA testing (no pun intended)? If someone were to tell me that their doc does a DRE, but does not request a PSA, then I'd have to tell them that “he must be doing that just for fun, cuz he surely ain't looking for prostate cancer”!

Too difficult to buy it,
adjust
Posted 5/5/2013 6:14 PM (GMT -5)
Phenom,

Exactly right. I tried to capture that sentiment earlier in the thread.

I was that guy in 2009 and even back then I remember seeing news about PC that generally left me feeling I didn't need to concern myself with "that".

What a collosal failure over the years to reach the average Joe.

The new guidelines made things much worse in this regard.

Thanks,
Jerry
Posted 5/5/2013 6:22 PM (GMT -5)
phenom, once again, we are saying the same thing, you too, jerry.

let them work on the overtreatment issue, not the screening side. if you have cancer, you need to know, and you have the right to be treated if needed. it should be this simple, why make it hard in war of words going on. this isn't just some intellectual conversation, we are talking about real men and real lives here. there's no prize for who's more right than another, let's think about the men, lets think about the 30,000 men still dying every year. that is where the focus should be.

david
Posted 5/5/2013 7:03 PM (GMT -5)
Ralph,

http://seer.cancer.gov/csr/1975_2008/results_merged/sect_23_prostate.pdf

This is the SEER data that looks at both the mortality rates and the incidence of rates of PC.
It shows mortality rates dropping by 3.5% a year for the 9 year period which is close to your 40% reduction, but also shows a 1.9% annual reduction in the rate of PC incidence. So the majority of the mortality drop was caused by a reduced incidence rate.
Posted 5/5/2013 7:40 PM (GMT -5)
My daughter is a family doctor.  She says that at the clinic where she works, they do not do routine PSA testing to screen for prostate cancer.

And so it goes.  

Posted 5/5/2013 11:22 PM (GMT -5)
Didn't say Samadi's radio bit was about AUA. It's about not testing.

Samadi believes in getting a baseline at 40.
Posted 5/5/2013 11:52 PM (GMT -5)
davidg,
Not testing is not what the AUA recommendation is saying so that's good...We have better testing guidelines from 4 years ago in place today from the AUA. I wouldn't want anybody to get the idea that the AUA is saying to stop screening because there could not be anything further from the truth.

Tony
Posted 5/5/2013 11:54 PM (GMT -5)
crossed signals I think.

Based on what Samadi has told me face to face numerous times he is not for the guidelines you posted on page 1. He is for getting a baseline at 40 and or African Americans and people wiht history in family to be even more cautious.
Posted 5/5/2013 11:58 PM (GMT -5)
I'm not going to stay in the debate on this. I have heard all the comments and been on many sides of this terribly controversial subject. I thank everybody for keeping the discussion peaceful. I just want to add that my work in the advocacy will always keep in mind all of your thoughts and passions about screening. I personally support the AUA for taking a much needed step of trying to counter the USPSTF recommendation that calls for the end to all screening.

Peace and love to all here that expressed their thoughts.

Tony
✚ New Topic ✚ Reply
12345678