It’s Time to Lay Down Our Rhetorical Arms and Get to Work
The recent USPSTF recommendation on PSA provides a teaching moment and an opportunity to move entirely beyond the PSA debate. But will others heed the call?
Emotions are running high ever since the USPSTF released their most recent recommendations on PSA screening last week. The patient advocacy community is running at a fevered pitch. The task force continues to defend its position. Leading organizations are responding as best they can while balancing multiple considerations and constituencies. Standing back, I see a lot of wasted emotions and energy, and not many real solutions being offered. It’s as if some of the players want to hold onto business as usual, drawing their raison d’etre from the controversy rather than calling for a time out and collectively defining a reasoned, science-based plan for curing more and overtreating less. The levels of unbridled passion exhibited threaten to erode credibility.
All sides need to acknowledge that the PSA test is not a cancer test and that it has its limitations. We also need more informed consent BOTH before and after PSA screening. Most importantly, we need to acknowledge that overtreatment of prostate cancer is as serious a problem as aggressive varieties of prostate cancer and the 33,000 deaths of American men they cause each year.
Yes, I, like many of the readers of this blog, believe that PSA screening saved my life. BUT… for as many of us as there are, there are many men who have been overtreated as a result of their diagnoses and suffer needlessly the possible consequences.
Cancer is a scary word. With more than 25 genotypes or varieties of prostate cancer, and no way yet to discern specifically between non-life-threatening and aggressive types in the current diagnostic process, overtreatment remains a problem. In my case, I might not particularly like the procedures and treatments I have had to and continue to endure, but I am blessed to be able to sit here and write this entry. However, I would not wish this reality on any man or family whose cancer doesn’t merit a similar course of treatment.
Advances in developing better diagnostic tests will soon ensure that we are serving the needs of men on both sides of the prostate cancer spectrum. One very promising example is the development of a new genetic-based urine test developed by researchers at the University of Michigan.
I have been working with the Prostate Cancer Foundation for three and a half years. This weekend, I put in many extra hours working with our leadership team and medical director, outlining our response to the USPSTF recommendations on PSA screening. I am proud to run the response in its entirely here. I hope all sides will see the logic behind the statement and push for greater collective investments in coordinated research.
We are so close to moving beyond this quagmire. It’s time to turn down the volume and turn up the action. Together, we can cure more and overtreat less.
PCF RESPONDS TO U.S. PROTECTIVE SERVICES TASK FORCE RECOMMENDATION ON PSA SCREENING
While needing better guidelines, the PSA test still plays an important role in detecting early prostate cancer in informed patients
LOS ANGELES/October 10, 2011—The mission of the Prostate Cancer Foundation (PCF) is ending suffering and death from prostate cancer through research. PCF received a copy of the U.S. Preventive Services Take Force report late Friday. Today, PCF issued its analysis of the heavily-debated recommendations of the U.S. Preventive Services Take Force regarding PSA screening in healthy men.
The Prostate Cancer Foundation:
• Supports continued routine PSA screening of informed patients until new American Urological Association clinical guidelines on PSA screening are issued and disseminated.
• Supports a patient’s choice to have a PSA test. The decision should be made between a man and his personal physician based on his individual status with respect to age, symptoms, family history or concerns about prostate cancer.
• Supports American Cancer Society communications calling for far better processes of informed patient decision-making both prior to, and after, PSA screening in healthy men.
• Opposes the elimination of reimbursement for an informed patient requesting screening.
• Strongly recommends intensified National Cancer Institute focus and research investment in better early detection tests of lethal prostate cancers. We also recommend new public-private research partnerships drawn from substantially increased and coordinated research investments from the American Cancer Society (ACS) and the American Urologic Association (AUA) partnering with the NCI and PCF. Such public-private partnerships will accelerate the discovery, testing, and validation in U.S. men of new biotechnologies for lethal cancer detection that are superior to PSA screening.
• Calls for greater patient participation in clinical studies evaluating new genomics-based prostate cancer detection tests.
• Calls for greater eligible patient participation in and physician referral of patients to ongoing new clinical trials evaluating Proactive Surveillance (watchful waiting).
The USPSTF has heightened awareness with new data of the issue of severe complications and patient suffering from the overdiagnosis and overtreatment of indolent prostate cancers. In addition to the emotional and physical suffering experienced by men and their families, a recent cost-effectiveness analysis of PSA screening estimated that the cost of diagnosis and treatment is over $5,227,306 per patient to prevent one U.S. prostate cancer death.
The USPSTF’s position provides a teachable and actionable moment for the medical community to improve targeting of PSA screening in patients, reduce over-testing and improve processes of patient education on the risks of overtreatment from PSA screening.
In the abstract, “task force” recommendations can create patient confusion and may result in unquantifiable numbers of men who will get a delayed diagnosis of a lethal and curable cancer. However, it should be noted that the recommendation clearly states, “…while the USPSTF discourages the use of screening tests for which the benefits do not outweigh the harms in the target population, it recognizes the common use of PSA screening in practice today and understands that some men will continue to request and some physicians will continue to offer screening. An individual man may choose to be screened because he places a higher value on the possibility of benefit, however small, than the known harms that accompany screening and treatment of screen-detected cancer, particularly the harms of over diagnosis and overtreatment. This decision should be an informed decision, preferably made in consultation with a regular care provider. No man should be screened without his understanding and consent; community-based and employer-based screening that does not allow an informed choice should be discontinued.”
PCF is encouraged that the AUA has convened a panel of medical experts who work routinely with prostate cancer patients, to improve guidelines for more targeted use of the PSA test as a screening tool.
Moving Past the PSA Debate
The PSA test still has a role to play in early detection and treatment for millions of men. It should be noted that in the pre-PSA era, approximately 80% of patients who were diagnosed with prostate cancer, were already in advanced stages of the disease with metastatic cancer. Today, the number of patients who are diagnosed with metastatic disease at time of initial diagnosis is around 20%. In the past 15 years, the death rate has been reduced from 42,000 annually to 33,000.
The PSA debate can become moot with intensive and accelerated research that delivers a better test. For more than a decade, PCF has been supporting research to find new and better molecular biomarkers for prostate cancer. At PCF’s 2011 Scientific Retreat, data on 17 new biotechnologies that complement or have the potential to replace PSA screening was presented. Many of these biotechnologies have the potential to discern between indolent and lethal prostate cancers. Essential will be patient participation in clinical trials to evaluate these new tests. New data on urine and blood tests using genetic biomarkers also offer the promise of eliminating a large number of unneeded biopsies and subsequent
Given the enormity of the problem of overdiagnosis and overtreatment, PCF is also supporting a $5 million research project, the National Proactive Surveillance Network, to determine which patients can be maintained on proactive surveillance and which patients need to be recommended for surgery or radiation. Additional clinical trials of proactive surveillance are urgently needed to develop guidelines for men whose cancer is not life-threatening.
To keep apprised of the latest developments related to the USPSTF Recommendations on PSA Screening visit PCF’s special Resource Center.
Yours in health… –Dan