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Urology group stops recommending routine PSA test

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Posted 5/7/2013 2:33 PM (GMT -5)
I think we agree.

Of course, what does overtreatment mean?

I think perhaps the real problem is that patients are not given a good view of the various possibilities. If I have a G3+3 say in 3 cores at 20%, my options certainly include surgery, assorted seeds/radiation, and AS. If I am the mindset of "get it out," then if I CHOOSE surgery, am I still being overtreated? That is not a simplistic question, especially when the evidence suggests that the G6 will not metasticize.

I do think there are still too many urologists who pressure their patients into quick surgery (ka-ching!), without encouraging their patients to investigate more options. For some patients, I guess that's just fine. But the doctor ethics in such a situation is not stellar.

Mel

Posted 5/7/2013 2:36 PM (GMT -5)
I agree that we're on the same page Mel - and I also believe your latest post is another spot-on well made point to be included in this discussion and topic.
Posted 5/7/2013 2:50 PM (GMT -5)
Mel/Yoop...I am obviously on the same page with both of you.  Continuing with your example, Mel, what would REALLY be helpful from the AUA is a suggestion as to how to handle the G6/3/20% you described.  If the AUA thinks that treating that is overtreatment, then a helpful guideline is to say so...e.g. indicate what level of cancer should be left untreated.

Of course that is hard work.  What is easy is to play around the edges with guidelines about testing...

Jim

P. S. to Tony:  I understand and appreciate your willingness to take an unpopular position.  But, given the overwhelming response of your "constituency" here at HW, doesn't it give you pause as to the validity of the position? 

Posted 5/7/2013 3:57 PM (GMT -5)
Just a few observations

1. See! I knew I could get all you guys united on something...:-)

2. It's funny how all of a sudden the "urodocs" first were doing the Ka-ching and now they are goats for reducing screening and over treatment...

3. The patient community in general feels basically that there is no such thing as over diagnosis.

4. The patient community in general wants every man to screen annually starting at 40 or even earlier for the rest of their lives..

5. See I knew JohnT and I would eventually agree on something...:-)

We have a long way to go on that happy median but it's ok to not agree on this. I am not against screening but like John, I think population based screening is the wrong thing to do. We need a better test before that ever happens. Just a note, less than 50% of men will ever get a PSA test. I also believe that if we are really concerned about preventable death rates to any ailment we should have every man check his weight and stop poor eating and exercise habits and quit smoking. And that should be long before he ever has a PSA test.

Peace

Tony
Posted 5/7/2013 4:06 PM (GMT -5)
I also believe that if we are really concerned about preventable death rates to any ailment we should have every man check his weight and stop poor eating and exercise habits and quit smoking. And that should be long before he ever has a PSA test. 

poor comparison but I realize you must grasp at straws.

ed

 

Posted 5/7/2013 4:12 PM (GMT -5)
Jim,
That's a fair question, but it doesn't change anything for me. I fully understand the position that many men share here.

But to think it's necessary to test every man annually at age 40 for the rest of his life?

I won't make that a crusade. And I won't be anything but informative as to what the various agencies and consortiums are recommending either when I speak about PCa. Stay tuned for ASCO next month. I'll be there but you won't need me to report on that news. I'm certain at least three miscommunicated variations from the press will set the patient community on fire again.

Tony

Post Edited (TC-LasVegas) : 5/7/2013 3:15:55 PM (GMT-6)

Posted 5/7/2013 4:16 PM (GMT -5)
It is an inexpensive test. Testing for men? Sure. Why not?
Posted 5/7/2013 4:23 PM (GMT -5)
Well it's not the cost of the test that's at issue. Every man can still get his tests if he wants them. The AUA is not ending screening by any means. They are just saying stop pushing the men into screening unless they meet certain criteria.

According to recent statistics 29,000 men will die from PCA in 2013. That's about the same number of men that will spend a week in the hospital from infections due to biopsy or repeat biopsy in AS cases. Forget the 50,000 men per year that have a radical therapy for a disease that would likely have never have been a threat to them.

We simply need a better test to help us separate the men who need treatment from the men who don't.

Tony
Posted 5/7/2013 4:47 PM (GMT -5)

TC-LasVegas said...
Jim,
That's a fair question, but it doesn't change anything for me. I fully understand the position that many men share here.

But to think it's necessary to test every man annually at age 40 for the rest of his life?

I won't make that a crusade. And I won't be anything but informative as to what the various agencies and consortiums are recommending either when I speak about PCa. Stay tuned for ASCO next month. I'll be there but you won't need me to report on that news. I'm certain at least three miscommunicated variations from the press will set the patient community on fire again.

Tony

I don't think Samadi says every year after creating a baseline at 40. If I recall correctly he had literature that said that more time could elapse if the results were good.
Posted 5/7/2013 4:48 PM (GMT -5)

compiler said...
I think we agree.
Of course, what does overtreatment mean?

I think perhaps the real problem is that patients are not given a good view of the various possibilities. If I have a G3+3 say in 3 cores at 20%, my options certainly include surgery, assorted seeds/radiation, and AS. If I am the mindset of "get it out," then if I CHOOSE surgery, am I still being overtreated? That is not a simplistic question, especially when the evidence suggests that the G6 will not metasticize.

I do think there are still too many urologists who pressure their patients into quick surgery (ka-ching!), without encouraging their patients to investigate more options. For some patients, I guess that's just fine. But the doctor ethics in such a situation is not stellar.

Mel

Fantastic point, Mel. That would not be overtreatment, that would be freedom to choose how to tackle this.
Posted 5/7/2013 4:56 PM (GMT -5)
But yes it could still be over treatment even if someone chooses to be treated. I mean no one was ever forced to have a radical procedure done. We all chose a therapy.

Whether we needed it or not is what over treatment is about.

Tony
Posted 5/7/2013 5:01 PM (GMT -5)
DavidG,
In your video Samadi clearly says to start testing in the 30's. He mentions baseline but does not elaborate on the frequency of testing.

Tony
Posted 5/7/2013 5:05 PM (GMT -5)
i think he says 30s for people with high chance and for African Americans. He's touched on this subject many many tiomes so i don't recall which video or press release. HE always tells me 40
Posted 5/7/2013 5:21 PM (GMT -5)
so tony, why don't you explain what over treatment is? what's your definition? who would you not treat upon a verified PC diagnosis?

also, we all agree, that at best, a biopsy is just an estimate of what is going on inside the prostate, based on the number of cores tested. how many times even here at HW have we seen biopsies underestimate either the amount of cancer, or the severity of it, i.e. increase in Gleason after surgery?

so how can we know in advance, if someone we tell doesn't need treating, based on their biopsy, really needed it more, once their entire prostate was removed and examined?

we would all agree, we need a better screening tool, one that not only shows the presence of cancer, but also whether it was indolent, intermediate, or aggressive, and I don't mean just a simple gleason number. what would be wrong with that?

if it could be proven that a man truly had an indolent cancer, that would never hurt him in his lifetime, then aggressive treatments could be denied for medical and insurance reasons, and men in that situation simply would be on AS, and only when and if things changed for the bad, would actual treatment be offered. A different version of what I have said for years here. Sounds fair and reasonable, and would cut down overtreatment in a safe and fair way.

Time to lay off the over testing and over screening argument, that benefits no one, especially the patient, and the best needs of the patients should be paramount over all other motivations.

david in sc
Posted 5/7/2013 5:24 PM (GMT -5)
and tony, why do you keep pushing the idea that we are saying that men need to be tested every year after age 40? not sure where you got that from. I say the original standard, at age 50 unless high risk, and lets say a 50 year old man had a PSA of <1, there would be no reason to test every year after that, would there? No one said or suggest every man, every year. Sounds like you are loading the argument in your favor by making an absurd suggestion on the other side.

david in sc
Posted 5/7/2013 5:29 PM (GMT -5)
 

DavidG said...
(I don't think Samadi says every year after creating a baseline at 40. If I recall correctly he had literature that said that more time could elapse if the results were good.)

DavidG,

I had a baseline at 40 simply because it was part of my bloodwork to check cholesterol.  PSA was good.  Didn't get a followup for 3 years when I just turned 44.  Yeah, I'd make it more frequent than 3 years. 

BTW - I didn't know anything about PC, but I do remember the media, even back then, giving complete mixed messages about screening.

And to respond to your much earlier post --- yes, being diagnosed in your 40s comes with unique challenges...that's for sure.

Jerry

Posted 5/7/2013 5:48 PM (GMT -5)
David (Purg)
Er...you said it. You disagree with statements 1-4 and you don't know about statement 5.

Statement 1 says to not screen men under 40. You disagree so I assumed that means you want men under forty screened.

Statement 2 says ok to screen the high risk guys from 40-55. You disagree with it so I assume that you want men screened regardless of risk in this age group?

Statement 4 says do not do annual screening. You disagree with it. I assume that means we should screen annually.

Maybe you don't disagree with these guidelines as much as you are saying? I don't know where you are with this except by what you say and you disagree with 1-4 and maybe 5.

You may have inadvertently indicated that screening before 40 annually at least until 70 maybe longer is the right thing to do.

Maybe you partially agree with the statements?

Tony
Posted 5/7/2013 6:49 PM (GMT -5)
tony, rather you try to answer my two posts, just above the "jerry" post right above this. let's see your answers on these items, as opposed to trying to entrap me on how I answered that.

to be clear, and this has been my view for 5 years:

all men should be tested beginning age 50.

how often it should be repeated, should depend on their base number

men at high risk should be screened at age 40 - African americans, men with proven PC in their father's side of the family, or those with unusual prostate issues at an early age

I would have no problems cutting off PSA screening at age 70, if PSA is still age adjusted "normal", and no unusual prostate problems.

now answer my questions from above, please

david
Posted 5/7/2013 7:24 PM (GMT -5)
David,
Your comments recited was not an entrapment. It was just what you said that indicates that nothing in the guideline statements are anything you agree with.

Purgs questions:
why don't you explain what over treatment is? Over treatment is treating a disease that does not need to be treated.

what's your definition? Treating a disease that does not need treatment.


who would you not treat upon a verified PC diagnosis? Follow the NCCN Guidelines that I have been touting for the last three years.

how many times even here at HW have we seen biopsies underestimate either the amount of cancer, or the severity of it, i.e. increase in Gleason after surgery? I don't know I didn't count them. But fair to say 10-15% possibly higher.

so how can we know in advance, if someone we tell doesn't need treating, based on their biopsy, really needed it more, once their entire prostate was removed and examined? I don't know. How many radiation patients know what their actual Gleason Score was when they never see the post operative pathology? And how can we say they really needed it post operatively? Either way there is no certainty.

we would all agree, we need a better screening tool, one that not only shows the presence of cancer, but also whether it was indolent, intermediate, or aggressive, and I don't mean just a simple gleason number. what would be wrong with that? Nothing. So where is that tool?

Tony
Posted 5/7/2013 7:42 PM (GMT -5)
Purg you asked one more question:

why do you keep pushing the idea that we are saying that men need to be tested every year after age 40?

Aside from you disagreeing with all of the AUA statements...

There are quite a few guys in this thread that could speak up and let you know that they would encourage screening at 40 and continuing to do so. Do you remember when the AUA came out with the baseline at 40? Do you remember the protest about screening them every year?

One more question for you. Do you believe in over diagnosis? If so, give us some examples...

If not, well then I'll give you a few...

Tony
Posted 5/7/2013 8:00 PM (GMT -5)
This is a stupid argument! Is there really anyone here that would tell a guy 40 or older NOT to get a PSA? I'd wager, no. All the other rhetoric should be reserved for AFTER the test.

Moreover... any male who CHOOSES a yearly physical should man up and tell their GP to never skip a DRE after 35! Truth. Many of us younger guys started down this road for one of two reasons:

1. We wanted insurance and were denied because of a "high" psa for our age... under 50, say. If you're denied based on a PSA, you have the responsibility to determine WHY!

2. We had a "bad" DRE upon a yearly physical.

#2 was me. I rode it out for a year oblivious to what the heck a PSA was. The next year, with the uncertainty of that new DRE, another PSA sent me to the "experts."

Ultimately, individuals are the Captains of their ship. BUT information is knowledge. Anyone here who would council a friend, "Don't worry about a PSA until you're 50." should be ashamed of himself. Ashamed!

I've said my piece and counted to five!
Posted 5/7/2013 8:26 PM (GMT -5)
Tony, now you say "over diagnosis"?

That's puzzling to me, how does this fit into the theme of this thread. How do you over diagnose someone? If a man has his base PSA at 50 (old standards), and there's no problem and has a negative DRE, then I wouldn't have any problem of telling him to have it re-tested, let's say, at age 55, and if still no problem, then again at 60. I am not suggesting every year, if there is no other issue, no rapid rising, and his PSA stays in what we would call proper age adjusted ranges.

Sounds like we agree about a better diagnosis tool, I have asked for that for years myself. But you kind of sounded like a S.A., when you said "Where's the tool". Not my job or ability to design this better tool, but realize its needed. The PSA and the DRE and even the biopsy alone/together doesn't tell us the whole picture. We need to know the strand, the aggressive nature or lack therof of a patient's particular cancer - that answer - should dictate the direction of treatment or even non-treatment.

I agree, that just because a man gets diagnosed with a G6, 1-2 cores, let's say <5% cancer, doesn't justify jumping into an invasive treatment. It that diagnosis is correct and fully, then it's highly unlikely that cancer will ever be a killer to that man, and yes, it would be overtreatment.

I want to see the conversation turn around from over-screening, to how can we deal fairly and effectively with overtreatment. Think we are beating a dead horse on the PSA/Screening side of this debate, as you can see, you not getting many takers on this.

David in SC
Posted 5/7/2013 9:26 PM (GMT -5)
...of course I understand that this thread is a Doctor Recommendations thread, but since people here, often cavalierly, imo, throw their advice around as if they were doctors themselves, I say that this is all ridiculous rhetoric. Just like the recommendation to not screen.

I reiterate... if an insurance co will deny you because you are a bad bet, which they will if your PSA is weird, then when you get to 40 YOU should be requesting it. Don't wait for medicine to say it's "appropriate," ask for it and get it. Problem is, that method requires US to tell friends and associates that it would be WISE for them to have a baseline PSA. But until insurance co's change their stance on giving life insurance to people who desire their insurance w/o a PSA, I cry foul. Those bean counters know things. Mark it.
Posted 5/8/2013 1:47 PM (GMT -5)
Well, we didn't get it done! All the discussion here seems to be meaningless since nothing will change..I had sincerely hoped that we could get the recommendation "overruled" like the BC recommendation was overruled or ignored for testing women in their 40's..Casey 59 said that issue was past; well, like sheep we were dazzled with science, evidence, facts, and SWAG estimates which in the main was outdated and erroneous..
The URO community cautioned not to take the take force to task so here we are..
Bill
Posted 5/8/2013 2:23 PM (GMT -5)
Bill,

I continue to be amazed how most everyone disagrees with the Task Force's recommendation, yet few take action.

JL

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