Prostate Management: Pig Farmers and Animal Histology. August 2013

This blog refers to the current document and its controversial rebuttals by Oncologists and Public Health Figures in Australia.

http://www.bjuinternational.com/bjui-blog/the-melbourne-consensus-statement-on-prostate-cancer-testing/

Released In Melbourne this week.  I have tried to place this into the context of my life as a busy Family Physician or General Practitioner depending on which part of the world you reside in.

As GP’s we have a different context to our medicine and are mindful that guidelines for Specialists are not necessarily applicable to Family Practitioners.  When they disagree it drives me crazy!!

Thank you to the Urological society for this important document and the subsequent and necessary debate.  I am a General Practitioner so I am not under the auspices of your college, nor the college of Oncologists.  Before I start and maybe it’s a bit controversial but referring to a Fellow College or practitioner as a Pig Farmer or being “like a Pig Farmer” is frankly demeaning to the profession and to this debate.  We all have cognitive biases.  I would plead with both sides of this important debate to recognise that what we all want here is an effective strategy for the benefit of the patient with the least amount of harms, both to that individual patient and to the population who ultimately pays the fiscal price.  Respectively to get the best voices to this debate, a more respectful thoughtful discussion might encourage other quieter voices that may have much to add. I plead with you to stop it.   There I said it. So that was the easy controversy.

http://www.medicalobserver.com.au/news/colleague-abuse-experienced-by-majority-of-gps

http://www.australiandoctor.com.au/news/latest-news/urologists-hit-back-in-psa-debate?utm_source=Cirrus+Media+Newsletters&utm_campaign=5411657cec-fe913f1856_57489&utm_medium=email&utm_term=0_fe913f1856-5411657cec-58630889

Our College has as its guideline for best practice on Prostate management a simple strategy: that is   “not to ask the patient regarding screening” and to discuss only in the context of a patient led enquiry.   The College has worked hard with a volunteer committee of Committed Drs examining evidence to come up with the best solution for Australia’s General Practitioners.

Whilst I acknowledge this very hard and excellent work I feel frustrated by its implications.  I recognise that a universal screening program for PSA testing in Australian men over 50 has cost limitations. The limitations include cost of the testing, lives saved, morbidity and mortality of the investigation of positive tests.  First do no harm is a worthy consideration amongst all the other players in this arena.

However it does feel rather an issue.  The stats are from the Cancer Council Australia’s page.

http://hope.cancercouncil.com.au/?gclid=CJXw6KCQ8rgCFWNNpgoduBUAxA

Prostate Cancer is the leading cancer diagnosed in Australia and accounts for 7.4% of all Cancer deaths.   Bowel is number 2 and accounts for 10.4% of all Cancer deaths; Breast is number 3 and accounts for 6.8% of all Cancer deaths in Australia.  So Prostate Cancer is an important Cancer, and it is being diagnosed it seems relatively well.  There is no age stratification on those figures and no attempt to calculate number of years of life lost. Someone dying at 89 years of age from prostate cancer is not the same as someone dying at 49 years of age from bowel cancer without diminishing the loss to both individuals and their families of course.

My issue remains with this common cancer, is it ethical for me to withhold this discussion from a man even if he doesn’t bring it up?  I don’t screen for Pancreatic Cancer and I don’t screen for Brain Tumours or Lung Cancers.   Lung Cancer is the 5th most common cancer by diagnosis and yet accounts for 19.1% of all cancer deaths.  The other ethical issue I have is that I treat individuals, not populations and I am not an economist.  I steadfastly refuse to bring economics into the ethics of treating a single individual patient’s predicament.  I have seen public and private patients treated differently within the medical community and I find that pretty horrid.  I am pretty sure that not everyone agrees with that, having a more pragmatic attitude towards the use of finite health resources and it goes somewhat towards the whole world health stance currently on the necessary politics of health care rationing.  As I said, I am a Family Physician, I treat individuals and I treat them in their community context.  That is all.  Take the economics of health care to the electorate.

I would think most General Practitioners, Family Physicians are aware that the Free PSA with a DRE is not a good screening tool on its own.  It doesn’t tell us which are the rabbits and which are the tortoises.  We know that.  But is the presence of a tortoise therefore the determinant that we don’t look for the rabbits?  Again ethics here.  To a man of 50 he may wish to make that informed decision himself.  A man of 90 may elect otherwise.  Context driven. 

And now for some Animal metaphors: noting the absence of any Piggery.

The Histology of Prostate Cancer:

Imageor    Image    or   Imageor    Image                                                                                                             

 Image

My issue with the RACGP guidelines is that men do not volunteer very much in any consultation from central crushing chest pain (reluctantly) and most unlikely some LUTS, urinary incontinence, nocturia, diminished urinary stream, frequency etc.   In the same way there are probably more men withholding a history of erectile difficulties than there are volunteering them to their Doctor.

As a GP I feel really uncomfortable not having this long involved and important discussion with men.  Do I have to wait until the prostate cancer has presented with metastases before I have this discussion?   My non medical partner says most men now he encounters are extremely confused about this debate and isn’t it our job to inform them?  Or will the lay press once again take control of this discussion or others with vested interests?

In General Practice when we assess someone for CVS risk as I pointed out on Twitter we do not rely on cholesterol alone. A decision aid is extremely useful.  Online ones are better for me than a piece of tree which I invariably have difficulty finding.

This link below is more in keeping and concordant with the RACGP guidelines that unless you have a family history or Lower Urinary Tract symptoms you may not need a PSA.

http://www.prostatecancer-riskcalculator.com/assess-your-risk-of-prostate-cancer?calc=1

Which after all is really what the don’t ask” statement is all about, but as I pointed out men are notoriously difficult (!) and taciturn historians when it comes to their health.  Men of interest in the 50-69 age groups we do not see often enough in General Practice.  So for me opportunity to inform and educate is important.  I don’t neglect to tell them about exercise, weight management and diet either when I take their blood pressure.

It may well be that a lot of men do not go on to have the PSA test after this discussion but at least they have had it and remain aware of what a Lower Urinary Symptom might be and might mean.

       Consensus Statement 1For men aged 50–69, level 1 evidence demonstrates that PSA testing reduces prostate cancer-specific mortality and the incidence of metastatic prostate cancer.

Well for me it will be after the aforementioned discussion and link or maybe I will find that piece of paper decision aid.

  Consensus Statement 3: PSA testing should not be considered on its own, but rather as part of a multivariable approach to early prostate cancer detection.

Ok so DRE, family history, prostate volume and ethnicity with future research working hard here to develop better biomarkers and imaging strategies.

Risk stratification is more difficult and one in which the Urologist plays a part in association with the General Practitioner.  This may occur after a PSA, either a baseline one at 40 as per the Urological Society suggests or after a discussion on the risks and benefits false positives and false negatives of the PSA test, and DRE.

  Consensus Statement 4Baseline PSA testing for men in their 40s is useful for predicting the future risk of prostate cancer.

I would like to see more informed discussion on the algorithm for a 40 year old PSA to stratify men who may not ever need a PSA in the absence of any other risk factors.  That would be nice.  As a GP I am still considering my response on this Statement.  I am interested to hear more if it indicates I can save a man any further need for PSA. Otherwise I am less comfortable with this recommendation at this stage.  Can I say I am still feeling my way on this one?

 Consensus Statement 5: Older men in good health with over ten year life expectancy should not be denied PSA testing on the basis of their age.

There is a similar discussion around breast cancer screening and the ethics of ageist screening.  To the individual involved who is still leading an active life, a discussion on the monetary value of their life to the community seems rather out of place in my consulting room.

Consensus Statement 2Prostate cancer diagnosis must be uncoupled from prostate cancer intervention

Intervention is now in the province of the Urologist as I as a GP, have tried to explain the diagnostic process and its complexity as it presents to me every day.  This discussion is made all the worse for General Practitioners and patients by disagreements between the various colleges.

 I believe Prof Bruce Armstrong and Prof Ian Haines discuss the issue they have regarding the costs including prostatic biopsy complications, anxiety, monetary costs to the community, loss of life years to an older man, incontinence and impotence.  They are not wrong to raise these important issues.

It is heartbreaking to hear a middle aged woman cry about the loss of intimacy in her marriage due to prostate cancer treatment and the inability of her partner to even discuss this with her.  This is truly a very sad circumstance especially after all the kids have often just left home! 

I do think as clinicians we are working towards the same end.  That middle aged woman above should neither be in great distress about the loss of intimacy in her relationship but neither should she be crying about the recent diagnosis of bony metastases in her partner.

I would like to thank the Urological Society for attempting to create some evidence based guidelines

I would like to thank the RACGP for attempting to steer Australia’s General practitioners with an evidence based guideline.  As it is a guideline I have added here my own personal take on its use.

I would like to thank the dissenters Prof Bruce Armstrong and Prof Ian Haines for necessary if at times, contentious caveats.

We are trying to predict the future after all and like breast cancer diagnosis, cardiovascular risk profiling it takes time to sort out the best way forward.   We only have the technology that is available today and I salute the researchers who are working towards better diagnostic, better investigation and better treatment tools.  As a General Practitioner I have to individualise treatment in a socio-cultural context and in my own context of understanding and tolerance of risk or uncertainty.

I felt compelled to write this and I hope it is coherent as it is vital that specialists understand that General Practitioners work in a different context.  We may be also stratifying cardiovascular risk and weight management along with a skin check in the same consultation.  We have to place the myriads of excellent discussion into the individual assessment of any single patient and bear the consequences of getting it right or wrong, or as it is at the moment, to be sure of neither.  We remain uncertain about whether we indeed first do no harm.   

I welcome discussion on the merits or otherwise of the blog post however references to Pig Farmers or other literary equivalents have no place in a scientific discussion of an important medical topic which requires both art and science to deliver in a coherent state to an anxious or not so anxious male population and the similarly afflicted Family Physician.

Karen Price

MBBS, FRACGP

6 thoughts on “Prostate Management: Pig Farmers and Animal Histology. August 2013

  1. Dear Karen,
    Thank you for writing a blog on this important and contentious issue. Although I am a urologist, l come from a large family of GPs and I fully understand how confusing this topic can be. I frequently get emails asking “what would I do?” in various circumstances. The last one from my sister had the subject line “PSA testing – HELP!!!!!”. When the well 50 year old asks at the end of his annual check-up, “what about prostate cancer?”, the answer is not as straightforward as adding a PSA test to the cholesterol blood request.
    So what are we to do? I led the group of international experts (all of whom have devoted their lives to prostate cancer and are very highly-published in the literature) in drafting the Melbourne Statement which we released this week http://www.bjuinternational.com/bjui-blog/the-melbourne-consensus-statement-on-prostate-cancer-testing . I am pleased with the key messages and have been impressed with the positive reaction we have had. The goal was to bring some clarity to the very confusing landscape for GPs in particular. Our brief was – put something together that can sit as a one-pager on a GPs desk and that can be applied in daily practice. Other documents (including the current version of the NHMRC document), are less easy to digest and in my view, will be difficult for many to interpret and embrace. Keep it simple.
    Regarding men in their 40’s, this is an area where other guidelines fail. If you set the bar such that only huge, randomised controlled trials will be considered as evidence, then we will never have advice to give these patients. However, we have excellent non-randomised evidence from observational studies conducted over 30 years, showing that baseline PSA testing in the 40’s is highly predictive of prostate cancer (and aggressive prostate cancer at that), and this data has been published in the world’s leading journals – BMJ, JNCI etc. Therefore why not accept this? This data forms the basis of Guidelines from the National Comprehensive Cancer Network in the USA, the European Association of Urology, the Royal College of Pathologists in Australia, the USANZ and others. Men in their 40’s are going to raise this topic in GP practices so why not at least inform them of this. My view is that to dismiss this does not serve men well, and deprives them of the opportunity to make a decision themselves about PSA testing as part of a shared decision-making process. If a man in his 40’s has a PSA at or below the median (approx 0.7ng/ml), his 25 year risk of prostate cancer is extraordinarily low and he can be reassured. I would review again ten years later. However the man with a PSA in the 90th centile (above 1), is at much higher risk and needs more tailored follow-up. I would do his PSA again one year later.
    To agree with the extreme view that we should abandon PSA testing completely is unreasonable as it clearly does some good for some men (as we have seen 30-45% cancer-specific mortality decline since its introduction), and is also unreasonable as PSA testing is here to stay. We just need to use it a little smarter as outlined in the Melbourne Statement.
    Declan Murphy, Uro-oncologist, Melbourne

  2. Dear Karen,

    Great article, and it summarises some of the issues we face in general practice well.

    As you probably know from the few times I’ve written about this, my interpretation of the evidence is somewhat contrary to this so called “consensus” statement. I am much more supportive of the RACGP (Australian) and USPSTF (American) positions.

    I think the first issue we need to face is one of clinical uncertainty. I think that we general practitioners are pretty good at managing it, but that this isn’t respected (generally) by our specialist colleagues. A good part of this I don’t believe to be about professional turf, but rather, the assumptions that underlie our different context of work.

    This “consensus” statement is predicated on one major assumption that I believe to be entirely faulty – that it is always better to “know”, i.e., have a diagnosis, or to actively engage in processes to assess risk, than to not do so.

    This is demonstrated by the second consensus statement: “Prostate cancer diagnosis must be uncoupled from prostate cancer intervention”.

    I agree entirely with this statement. However, we should examine what this statement actually implies. The reason that diagnosis should be uncoupled from intervention in this disease is because of the protean nature of the “disease” in the first place. This logical conclusion of this consensus statement is that we shouldn’t screen for prostate cancer at all as early case finding is “uncoupled” from intervention.

    Wilson’s criteria for screening tests:
    – the condition should be an important health problem
    – the natural history of the condition should be understood
    – there should be a recognisable latent or early symptomatic stage
    – there should be a test that is easy to perform and interpret, acceptable, accurate, reliable, sensitive and specific
    – there should be an accepted treatment recognised for the disease
    – treatment should be more effective if started early
    – there should be a policy on who should be treated
    – diagnosis and treatment should be cost-effective
    – case-finding should be a continuous process

    I agree that we all see individuals and not populations, but we need to take care that we are not throwing out the baby with the bathwater. How do we know what works for our patients as individuals? We need to recognise that our clinical experience is another form of “population” based evidence, the population of our previous patients. However, this type of evidence is bias-prone and unsystematic.

    As you have pointed out, we don’t raise conversations with patients about many things – the clinical time we have is a precious resources. If a patient doesn’t raise the issue of PSA screening, I see little reason discussing it. In the relevant age group, we will already be discussing with this a range of other screening and preventive activities. I believe that we should initiate this discussion if the patient has PREVIOUSLY undergone PSA screening.

    With regards to the “risk” calculator, I personally have serious issues with it. Again, it is the issue of assumptions. The idea that someone at higher than median risk should undergo screening is nonsensical. Cardiovascular disease risk screening is based on ABSOLUTE risks, not that “you are at higher risk than 50% of men like you”.

    A serious flaw that this consensus statement doesn’t address is the most important of all. Does PSA screening as a strategy actually lower mortality and morbidity in the population screened? The answer to this is almost certainly “no”. Overdiagnosis and overtreatment remain major issues. Importantly, there is absolutely no evidence that more “tailored” screening methods reduce the impact of overdiagnosis and overtreatment. Moreover, the claim that it compares favourably to breast cancer screening is a palpable misrepresentation of the evidence.

    Metaanalysis of (that is, combining many different) breast cancer screening studies would suggest that perhaps about 1 in 4 breast cancer diagnoses are overdiagnoses. This consensus statement only cherrypicks the most supportive data. Even if we look at the MOST supportive data, the Goteborg data, 12 men will need to be treated for 1 to benefit. That is, the majority of men diagnosed with prostate cancer through screening are overdiagnosed.

    Prostate cancer screening only compares favourable to breast cancer screening if you compare the benefits but ignore the harms.

    Lastly, my opinion as a GP who works both clinically and as an academic is that guidelines that give instructions to primary care practitioners, but failed to include any GP involvement in its development, lack authenticity. To be blunt, it is condescending to GPs, and demonstrate a certain arrogance. Reading these consensus statements, my impression is that those who wrote them lack an understanding in the primary care context, and have failed to understand the requirements of screening programs at a public health level.

    Your sincerely,
    Michael

    • Thanks Michael and Declan who sit opposed on whether or not there is Level 1 evidence.

      Consensus Statement 1: For men aged 50–69, level 1 evidence demonstrates that PSA testing reduces prostate cancer-specific mortality and the incidence of metastatic prostate cancer. In the European Randomized Study of Screening for Prostate Cancer (ERSPC), screening reduced metastatic disease and prostate cancer-specific mortality by up to 30% and 21% respectively in the intent-to-treat analysis, with a greater reduction after adjustment for noncompliance and contamination[2,3]. In addition, the Goteborg randomized population-based randomized trial showed a reduction in metastatic disease and prostate cancer mortality with screening starting at age 50 [4].

      Is it possible for the Urologists to defend the cherry picking accusation?
      I do find it hard to understand how an international panel of Urologists would be so arrogant to put themselves out for an academic fall out by failing to include or consider contra evidence.
      Maybe I am an idealist but I am pretty sure that no one in my recollection of medical school enjoyed being humiliated for an obvious flaw.
      I note that the consensus statement first line sugggests PSA testing and only the second line suggests PSA screening when referring to the evidence. Does line 1 of the consensus statement suggest that the low risk men identified on a mulitivariate appraisal of their prostate risk were excluded?
      I dont think anyone argues that the PSA alone is enough for an analysis of Prostate risk, but coupled with other factors like ethnicity, prostate volume, DRE, age,PSA velocity, and family history are we then better able to have a discussion and quantify those risks to a man at 40, 50, 60 or 70?
      Should we be the ones deciding this?
      My point being that I feel uncomfortable withholding the evidence that we do have on the risks/benefits from any individual.
      Why do we talk about weight management as unless obese for instance there is a lot of argument about whether a BMI of 25-29 has major mortality issues??
      Its not a simple good PSA-Bad PSA argument but an overall approach to an illness which is the leading cause of cancer diagnosis in Australia and accounts at this stage for 7.4% of cancer deaths.

      Is it not possible we are talking at cross purposes or have the Urologists been disingenuous here. I am sorry Michael but I dont believe that arrogance plays a part. I think we all have a role to play in discussing this. I dont feel at all patronised by the College of Urologists and I welcome the dissent on the consensus statement. I wish to be convinced if you like as a swinging voter. To not inform and educate patients I feel is disingenous for the reasons I outlined in the blog. If men dont ask their GP Michael, they will ask the blokes at the gym, in the office and anywhere else they hang out??

      I do think it is an awful waste of life to have a man present in his 50’s or 60’s or 70’s + with metastatic disease without informing him of the current debate. I dont wish to patronise my patients nor do I want to signal to men thats its okay not to talk about their health just when the generations are starting to become interested in it. I would see that as a missed opportunity for General Practice collaborative decision making. I hope Declan and others respond to this discussion.

      My argument consisted of agreeing with the RACGP that perhaps in the abscence of LUTS that a PSA might not be advantageous but to have that discussion with the man based on the population studies. ( And I am not against the population studies by the way as they are the only bit we’ve got to go on) But it seems a little too bad if you are in the 7.4%, whereby the personal stat is 100%. I just dont think that not inviting this discussion at all has an ethical issue for me. Our role is to educate and men are confused about what to do? You know how reluctant they are to consider any health issue. Would it be better for the RACGP to have issued a statement discussing the issue surrounding LUTS and PSA??

      karen

      • Dear Karen,

        The issue is not withholding information from patients. Clearly, we as clinicians should not do this if we are asked. The question, however, is should we initiate the conversation in someone who does not ask?

        As you have pointed out, the issue here is the therapeutic benefit in doing so – which comes back to the major meaningful question we SHOULD be asking. It isn’t “could PSA screening save lifes” – clearly it COULD make a difference to an individual person. The question is “DOES PSA screening result in more benefit than harm when it is implemented as a population strategy”?

        The best evidence for this so far is that it probably does not. If we are honest with ourselves, that’s the message that we should give. I’ve done the calculation for this before (using the European data, it’s on J4D I think) – if the average Australian GP did PSA screening for all their male patients aged 50-69 over a 40 year career, they have better than average odds of not preventing a single prostate cancer death, as a result of the screening.

        Regarding LUTS, it is interesting that there is so much focus on this as part of the discussion. If you look at the USPSTF guidelines, LUTS is not considered a reason to screen. Yes, the majority of people with serious prostate cancer will have LUTS, but the majority of people with LUTS won’t have serious prostate cancer.

        I think that the philosophic position of this consensus guideline is summed up by the recent tweet by David Malouf: “simple message – maximise good & minimise harm thru early detection & no over-Rx”.

        I’m all for maximising good and minimising harm! However, it is an ideological position to believe that “early detection” is a necessary component to do this, or that it is always beneficial. I refer again to the aforementioned Wilson’s criteria. Those in the public health space acknowledge that although early detection may be a useful heuristic approach, it can be problematic.

        Simply put, early detection and early diagnosis is of no benefit if we cannot change meaningful patient outcomes within acceptable boundaries of harm. As before, it is not good enough that we think that we “could”. By definition in screening, we are potentially giving pathological labels to people who are otherwise perfectly well. Screening is assumed to be harmful, but can be justified if there are clear empirical benefits. We are not there with prostate cancer screening, and it is doubtful that PSA based screening will ever meet the Wilson’s criteria.

        Regarding my comment on “arrogance”, perhaps that statement is overly strong. Nevertheless, I am continuingly dismayed by the production of guidelines by specialist groups where substantial implementation necessarily must occur in the primary care setting, with no general practice representation. To be blunt, we in general practice ACTUALLY do pragmatic implementation of screening programs in multiple areas. We have effectively at some level been engaged in de-facto prostate cancer screening. Undifferentiated primary care patients don’t see urologists for screening.

        Lastly, I have a sense the the whole patient perspective is being lost in this debate. Yes, prostate cancer is important. However, on the list of preventive care priorities, it should be way down the list. Our interventions into other patient behaviours such as smoking, nutrition, alcohol and physical activity are much higher yield.

        Yours sincerely,
        Michael

      • Hi Michael,
        Thanks again. It does generate a lot of discussion. I have looked back through the Just4Docs forum which was a good discussion. Dr Jane Crowe who works at Prostate Australia suggested that there has been a 20% decrease in deaths from Prostate cancer since screening began in the 1990’s.
        We all acknowledge that a PSA cannot tell us which is the aggressive and which is the indolent cancer. Yet there is a proposal that Active surveillance may reduce the harms from overtreatment.
        I still have not had a clear answer on the Urological Society stating Level I evidence for the benefit of Prostate screening and the dissent which suggests this is not Level 1 evidence. This seems a pretty important piece of the debate to address.
        I will quote again
        EG Consensus Statement 1: For men aged 50–69, level 1 evidence demonstrates that PSA testing reduces prostate cancer-specific mortality and the incidence of metastatic prostate cancer.

        Dr Crowe suggested that the Number needed to treat from the Goteburg trial was 12 men to save 1 life and that those with a Gleason nscore of less than 6 have active surveillance.
        Is not active surveillance a method now being increasingly employed to minimise the harms of indolent prostate cancer intervention?

        My argument is not really the risks/benefits as this is one the statisticians can bounce around with. My argument is the suggestion that only men who raise the issue with us be fully informed.
        I suspect this means that educated white middle aged men of a certain income will benefit from access to health care and their education and that men of lower socioeconomic standards, of lower education levels, who have poor access to health care will
        Have worse outcomes if we only rely on informing those men who ASK.
        At the recent consensus meeting for instance it was pointed out that Aboriginal men had a much lower chance of prostate cancer but a much higher chance of dying from it.

        And I do agree with you regarding the benefits of smoking and exercise interventions. Prostate cancer is still the 4th leading cause of death in Australian males, after IHD, lung cancer and cerebrovascular disease.
        It seems reasonable to bring it up with them. Educational and socioeconomics class notwithstanding.

        I am not sure which diagnostic pathway in Medicine followed by a treatment pathway, has a perfect outcome for minimisation of harm and maximisation of benefit.

        Dr Karen Price
        MBBS, FRACGP
        Twitter@brookmanknight
        Linked In

  3. Dear Karen,

    I’ve put a separate reply here as I think we’ve maxed out the number of levels of “reply” above.

    Yes, there has been an absolute decrease in the mortality from prostate cancer which is excellent. However, we need to disentangle what this is from. Is if from screening, or is it from better treatment? This is the reason why the PLCO and ERSPC trials were so important – to prospectively determine whether PSA screening as a strategy actually reduces mortality, and if so, by how much.

    I agree that the ERSPC demonstrates an approximately 20% RELATIVE risk benefit to prostate cancer mortality from screening, and of the two studies, it is likely the one that may give a better picture due to some methodological problems with the PLCO. However, we must recognise that the absolute benefits are very small, and it was at the substantial cost of overdiagnosis and overtreatment. The Goteborg subset of the data is frequently brought up as evidence that PSA screening, but this is by definition cherry picking.

    Imagine this analogous situation: we are testing a new anti-cancer medication. Two big trials are performed. One shows no benefit compared to placebo, and one shows a minor benefit. Proponents of this new intervention then take results from a sub-cohort of one of the studies who did particularly well and proclaim: “See! This drug works and it saves lives!”

    This is a simplification but it is how some of the data from the prostate cancer screening trials are being used. The Cochrane Database of Systematic Reviews updated their review on screening for prostate cancer in January 2013. Their conclusion on the state of the evidence is markedly different to the recent consensus statement:

    “Prostate cancer screening did not significantly decrease prostate cancer-specific mortality in a combined meta-analysis of five RCTs. Only one study (ERSPC) reported a 21% significant reduction of prostate cancer-specific mortality in a pre-specified subgroup of men aged 55 to 69 years. Pooled data currently demonstrates no significant reduction in prostate cancer-specific and overall mortality. Harms associated with PSA-based screening and subsequent diagnostic evaluations are frequent, and moderate in severity. Overdiagnosis and overtreatment are common and are associated with treatment-related harms. Men should be informed of this and the demonstrated adverse effects when they are deciding whether or not to undertake screening for prostate cancer. Any reduction in prostate cancer-specific mortality may take up to 10 years to accrue; therefore, men who have a life expectancy less than 10 to 15 years should be informed that screening for prostate cancer is unlikely to be beneficial. No studies examined the independent role of screening by DRE.”

    http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004720.pub3/abstract

    I think that there is no question that advances in uro-oncological care that have reduced mortality. This data also suggests that we (collective we) may have also been fooling ourselves that early detection through PSA/other methods have made much of an impact in mortality.

    Regarding your argument about raising the issue with men, etc., I take your point. However, the question that must be raised is “what are we informing them”? Do people from rural/remote areas, and low income communities have poorer health outcomes because of LESS ACCESS TO SCREENING, or less access to health care generally? I very much suspect that it is the latter. That is, strengthening community access to timely and affordable primary care, and proactive approaches to preventive activities generally, and timely and affordable access to secondary and tertiary care when needed is what will reduce the prostate cancer outcome inequities.

    Yours sincerely,
    Michael

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