Post by Jody on Aug 1, 2015 2:52:02 GMT -8
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 sent the above as an email to the American Academy of Family Physicians for comment on 7/29/15. 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
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 sent the above as an email to the American Academy of Family Physicians for comment on 7/29/15. 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
