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Post by Tony Crispino on Jun 12, 2014 9:50:57 GMT -8
About all those lives that will be lost? In what I find totally unsurprising the US Preventive Services Task Force (USPSTF) Grade D recommendation to end prostate cancer screening in the US has had no effect on such screening in the US. I also suspect that there has been little to no effect on screening by screening guidelines from the AUA, NCCN, ACS, NCI, and just about any paper on screening out there with regards to targeted screening, when to biopsy, and regrettably when to treat. The last sentence is my own observation but I'd be willing to bet that screening of men in their 40's is on a steep rise. Use of active surveillance is also on the rise but only marginally and will not offset increases in treatment. From the attached file: "The current study found that even though the US Preventive Services Task Force recommended in 2008 to limit screening in older men with fewer than 10 years of RLE and stop screening altogether for those aged 74 years and older, screening rates did not significantly differ between 2005 and 2010." "The most frequently screened men were the healthiest men: those aged 65 years to 74 years who had less than a 27% chance of dying within the next 9 years. Approximately 58% of this group was screened in 2005 and 56% was screened in 2010. Of the men aged 75 years and older who had a 76% or higher likelihood of 9-year mortality, 36% underwent PSA screening in 2005 and 34% were screened in 2010." "'Prostate cancer screening for many patients and clinicians has become habituated. They need to be made aware of changes in guidelines and the importance of individualizing the screening decision.' The article in the attached file also notes that there are validated decision aids available from the ACS and other organizations, but says they are rarely used." My thoughts... As we continue the trend in the US to screen as early and often as possible we face a sort of continuing crisis in the healthcare industry. Prostate cancer is the most common and one of the most expensive cancers, if not the most expensive cancer, in healthcare. Many new biomarker decision aids are being very slowly adopted and probably due to the fact they have not been scientifically proven as yet. And that will take years to do. Until then the only method to curb over treatment is patient education and that has not been very strong either. From a recent post on the InfoLink, Mike extracted the following information: - Nearly 2.8 million men are living in America today after a diagnosis of prostate cancer (that’s 1 in 5 of all American cancer survivors).
- Prostate cancer patients diagnosed with local or regional disease now have a 5-year survival rate of nearly 100 percent and a 15-year survival rate of 91.4 percent.
- Many prostate cancer survivors have to deal with long-term effects of treatment, including the common problems of urinary incontinence, sexual dysfunction, bowel issues, adverse psychosocial effects, and relationship effects (but see the long list in Table 1 of the original article).
- Some 20 percent of all patients “experience treatment-related regret or feelings of loss or distress”.
- Please see this link for the full InfoLink article.
ACS Issues New Prostate Cancer Survivorship Care GuidelinesAnd the beat goes on...
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Post by Mike Scott on Jun 13, 2014 7:03:09 GMT -8
I should just clarify that the 5- and 15-year survival data in the ACS article that Tony mentions refer to RELATIVE (as opposed to crude or ABSOLUTE) survival data.
A relative prostate cancer survival rate over a particular time frame is a comparison of the observed survival of all patients diagnosed with prostate cancer compared to the expected survival of men of comparable age and date of birth who are not diagnosed with prostate cancer over the same time frame.
The ABSOLUTE survival rate is a very different animal.
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jasr
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Post by jasr on Jun 14, 2014 6:34:08 GMT -8
I agree with your post . As an Internist I have not changed my screening patterns except to explain to each patient the implications of doing the PSA test in addition to the DRE. I will state that even after explaining PSA,low grade PCa, and results that can occur , I .as of now. have had no one say "don't do the PSA", James
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Jerry
Junior Member
Posts: 44
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Post by Jerry on Jun 14, 2014 18:17:41 GMT -8
Tony,
I'm sure you know how I feel about this...so all I'm wondering is....who is this Mike Scott guy?
Jerry
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Post by KC on Jun 17, 2014 10:43:43 GMT -8
I agree with your post . As an Internist I have not changed my screening patterns except to explain to each patient the implications of doing the PSA test in addition to the DRE. I will state that even after explaining PSA,low grade PCa, and results that can occur , I .as of now. have had no one say "don't do the PSA", James jsar, thanks for sharing personal observations from your practice. And while your comment does go directly to Tony’s original posting, I believe that the most important point behind all of the new PSA screening recommendation changes remains unaddressed here…(so far).
The “end-point” objective of the Task Force was not to reduce PSA testing. Rather, the true “end-point” objective was to reduce overtreatment of low-risk PC. I believe this is the true objective of every single medical organization which has rewritten their PSA screening recommendations in the last 2-years: reduce low-risk PC overtreatment.
AUA, ACS, USPSTF, and all the others with new guidelines have been clear (some were quite clear, and others could have/should have been much more clear on this point) that through proper patient education about the true nature of low-risk prostate cancer (and how it is different than so many other “cancers,” men will be less inclined to over-react and request an aggressive treatment that likely has more harms than benefits. Patient education before or at the time of testing is absolutely the common thread in all the recommendation changes.
If we may assume for a moment that jsar is our illustrative example of an internist who often resides at the very front-line of PSA screening, it sounds like those changes ARE being made in community practices, and doctors ARE now doing more to educate patients.
I, for one, am not surprised that the decision is NOT widely being made to forego the PSA test. What I do truly hope is happening is unaddressed (so far) in this thread…is there any reduction due to better patient education (following the screening guideline changes) on the rate of overtreatment of low-risk PC…?
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Post by Tony Crispino on Aug 13, 2014 12:31:56 GMT -8
With trending discussion on the topic going around. I will just bump this discussion up.
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twolf
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Posts: 16
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Post by twolf on Aug 20, 2014 19:37:06 GMT -8
A number of hospitals in our area have stopped public screening events. Some claim liability issues: if something goes wrong during, let's say a follow-up biopsy, the question will be raised " why were you screened against recommendation by the Task Force?
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Post by Tony Crispino on Aug 20, 2014 22:23:48 GMT -8
Mass screening days in Las Vegas are still abundant. The facility we use for our UsTOO meetings still has them and there are screening events sill popping up at about the same rate.
Remember the AUA and NCCN both do not recommend mass screening events every quarter. And the estimates for the NCI have 2015 as the most prolific screening years in their estimates. ACS states that today there are 2.9 million men living with a dx today, and they predict by 2024 that number will be 4.5m.
This still shows a great deal of screening going on and expected to continue.
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twolf
Junior Member
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Post by twolf on Aug 21, 2014 14:07:49 GMT -8
www.cowtowncruisinforacure.org/ Carshow with proceeds going to prostate cancer; includes screening! Some hospitals moved to screening at the hospital; imagine this: public screenings used to be free; now you go to a hospital to get screened and you pay for it. What a great concept!
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Post by Allen on Aug 21, 2014 15:03:06 GMT -8
I think mass screening events are a terrible idea unless education is part of it. No one younger than 55 should be allowed to do it without advice of physician, and then only with a family history, African-American, urinary symptoms, or positive DRE. Without education first, it is sure to perpetuate the unnecessary maiming and suffering that has characterized the last 10 years. Everyone 55-70 should be required to go through a Patient Decision Aid first.
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Post by Tony Crispino on Aug 21, 2014 15:32:32 GMT -8
Allen, to you point, I did a search in Las Vegas for Free PSA testing and found a Urologist offering them all year around. At first I cringed. But I looked at his website and on the front page he has what is called a "Decision Point" and a link that is listed as "Am I ready for a PSA test" Decision Point webpage for Dr. Victor GrigorievIt has six tabs a a quiz to help arrive at the decision to screen. It's pretty impressive. I do like this. Have a look.
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Post by Allen on Aug 21, 2014 19:04:30 GMT -8
Thanks, Tony. I think that is a very responsible approach. I also very much like the ASCO Patient Decision Aid because it shows the statistics in a graphical way for those of us who relate better to pictures than to numbers. Using any such tools to get the patient and the clinician talking before jumping into a test seems like a great idea to me. ASCO PSA Patient Decision Aid.pdf (112.23 KB)
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twolf
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Post by twolf on Aug 22, 2014 6:58:13 GMT -8
Understanding that the quoted decision aids address PSA testing only, what about the DRE? What if you have a positive DRE (which a number of men still get), does that change anything? Seems that Allen agrees on this. Do you accept the PHI test as a great improvement? If yes, does that change the decision aid process? And what is wrong with the NCCN recommendation to start testing at 45? There 2014 process for early detection seems to be very logical. Waiting for symptoms is very dangerous (and that should be spelled out in the decision aid material) as there are no symptoms for early stage PCa.
I am very much aware of testing leading to unnecessary treatment (which is the real issue), but we need to also realize shortcomings of existing decision aid material and we need to recognize evolving technologies regarding testing (PHI test) and biopsies (MRI guided) - and I understand that these technologies are not widely available.
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Post by Tony Crispino on Aug 22, 2014 8:19:11 GMT -8
The DRE is typically not a free part of public screening, at least the ones I attended. That's hit or miss depending. But if you are headed into a urologists office, in the case of this doctors too, it would be an easy opportunity. I'll ask him when I write him. I am traveling right now so I can't do so today. The PHI test is a great improvement but it has not typically been used as a screening tool but rather a test to determine if a biopsy is needed. A close friend of mine is a distributer of that test and I have the presentation where it states that while it can be a part of screening, it is only intended to see if a biopsy is necessary. I like all NCCN guidelines. But many do not. Especially those younger than 45 at Dx. I agree waiting for symptoms can be an issue, but since I know many men that exhibited symptoms in their 30's and below age 45, it would seem that this can be an issue no matter where the line is drawn. There is no consensus. Should it be a part of the equation on the doctor/patient discussion? I think so. And it kind of is in this tool. But the guidelines for the tool right now are "When screening Asymptomatic men" per the NCCN, AUA, as well as the USPSTF menagerie. I have a thread here on biomarker tests. You may like? New PCa Biomarkers
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twolf
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Post by twolf on Aug 22, 2014 9:03:13 GMT -8
The DRE WAS part of most screenings in the DFW area. You are correct about the PHI test; it is actually used only if the PSA is larger than 4 and less than 10 per current directives. With the argument that PSA testing MAY lead to unnecessary biopsies (and treatments), it would still be partially eliminating the arguments against screening. Great link on the biomarkers, thanks.
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Post by Allen on Aug 22, 2014 9:57:12 GMT -8
twolf,
The majority of DREs are negative (T1c) even though there is PC present, so it is a very low sensitivity test (worse than flipping a coin!). The specificity (false positive rate) is only a little bit better, but is still affected by prostatitis and calcifications. Adding to the problems with the DRE is the fact that many clinicians just don't take the time to do them thoroughly. Interestingly, engineers are developing robots that may do it more accurately. Also, only the posterior of the prostate is reached. But if there are lumps felt, I think they would be sent for a PSA test. It is unclear whether PSA is increased immediately after a DRE and for how long.
I think PHI is an improvement over PSA, although I wouldn't characterize it as a "great" improvement. Unlike PSA, there is a cut-off where it has both decent sensitivity and specificity. At a cut-off of 35, PHI will correctly find 65% of prostate cancers (35% false negatives), and the false positive rate will also be 35%. See what I mean? It's good, certainly better, but not great. Ideally, we want a test that has a cut-off where the sensitivity and specificity are simultaneously above 90%. It will probably take a combination of biochemical tests (e.g., PHI and PCA3 and TMPRSS2:ERG fusion) to achieve that.
I don't understand why Beckman Coulter is only allowing PHI to be ordered by a limited list of doctors for now. The other benefits of the test are that it is cheap ($90, I think) and guaranteed to be covered by insurance.
In addition to preventing unnecessary biopsies, it has been used to track progression on Active Surveillance.
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twolf
Junior Member
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Post by twolf on Aug 22, 2014 17:44:55 GMT -8
Even though the anterior section of the prostate is not reached, it is believed that the volume reached by DRE contains 85% of prostate cancers (apparently that is not true for African-Americans!). Found this quote in www.health.harvard.edu/blog/harvard-expert-urges-caution-for-use-of-new-prostate-cancer-test-201207024990"According to clinical data that Beckman Coulter submitted to the FDA, using the PHI score could prevent about one in seven unnecessary biopsies while still detecting 95% of cancers." The 95% quoted here are much higher than the 65% quoted by you, can you please comment? At one time we were told that PSA or DRE alone will detect about 35% of cancers, while a PSA/DRE combination is capable of detecting about 65%. Allen, do you have any data on that, and, without digging to deep, can you provide references? Thanks
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Post by Allen on Aug 22, 2014 20:25:38 GMT -8
twolf- Beckman Coulter is understandably hyping their test. It's all about what cut-off they choose to publicize. Just like all medical tests, there is a trade-off between sensitivity and specificity. For PSA and % free PSA, there is no cut-off that simultaneously allows for detection of almost all cancers while eliminating almost all unnecessary biopsies. PHI is somewhat better, as I said. My numbers are drawn from the Catalona study that was used to get FDA approval. You can understand the trade-off if you look at the linked table. (Table 2) If you want a cut-off that detects 95% of cancers, you will need to go down to 21.3, but at that cut-off, the specificity is only 16%, which means that 84% of men will be sent for unnecessary biopsies. Now to understand Beckman Coulter's hype, you have to look at the chart they post carefully. They look at Table 2 for the PHI test with 90% sensitivity, which occurs at a cut off of 24, and has a specificity of only 26% - 74% of men will be sent for unnecessary biopsies at that cut-off! Then they looked at the PSA test. To reach 90% sensitivity, the PSA cut-off would have to be around .5 (I'm estimating) and the sensitivity is only 8% by Catalona's numbers -- 92% of men would be sent for unnecessary biopsies at that low a PSA cut-off. So their claim that PHI at 90% sensitivity is 3x more specific (=26%/8%) than PSA and would result in 20% reduction (=(92%- 74%)/92%) in unnecessary biopsies is technically true, but as you can see, you would never use that cut-off because it would still send 3 in 4 men to unnecessary biopsies. Notice on the chart they post, they define a new term "Relative % Specificity" because they don't want you to be aware of how low the actual specificity is.
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twolf
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Post by twolf on Sept 1, 2014 17:45:30 GMT -8
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brucevein
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Glad to be here!
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Post by brucevein on Oct 1, 2015 7:49:13 GMT -8
My father passed away from prostate cancer. It seems that in society the people who need to be screened never get it done because of financial or time related issues. Everyone has known for years that prevention is key and catching symptoms and getting a diagnosis early are imperative. I work in the medical field now and although I don't deal with urology. I deal with cancer patients who have other types of issues as well. Leg Cramps Las Vegas
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