Friday, December 23, 2011

U.S. Preventive Services Task Force recommendations of PSA screening for Prostate Cancer

How many of you read the following types of news article earlier this year?

Or this one,

I know a lot of my patients did and I’m disgusted.  The articles made statements such as;

The U.S. Preventive Services Task Force, which advises the government on health prevention measures, on Friday downgraded its recommendation on prostate cancer screening to a "D," which means it recommends against the service because "there is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits”


“Healthy men should no longer receive a P.S.A. blood test to screen for prostate cancer because the test does not save lives over all and often leads to more tests and treatments that needlessly cause pain, impotence and incontinence in many, a key government health panel has decided.”

Where do I start. As seems to be all so common with the mainstream media, they left out a few important facts from the recommendation from the USPSTF. It make for much more sensationalist articles. The grade’s came from the 2008 article. The newer 2011 article made no such recommendations. This newer article just stated that Prostate-specific antigen–based screening results in small or no reduction in prostate cancer–specific mortality and is associated with harms related to subsequent evaluation and treatments, some of which may be unnecessary.”

Let’s evaluate the 2008 recommendations, the first of which is;

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening in men younger than age 75 years.

Let me paraphrase here, in men younger than 75 years old the current evidence is insufficient to assess the balance of benefits and harms of prostate cancer screening

The second recommendation was: 

The USPSTF recommends against screening for prostate cancer in men age 75 years or older.

Let’s deal with the second recommendation first. If you are 75 years old and are diagnosed with Prostate cancer there is a pretty good chance you are going to die of something else. This statement is statistically true, but I personally do not want to be treated as a statistic. Simply this means mean more than half of the people will die of something else. Maybe even 90%. But what if you are one of the men that won’t. Prostate cancer typically metastasizes to bone which can be very painful. Without diagnosis and treatment it’s can be a miserable death.

I personally think we need to be more intelligent with our evaluations. For example if we have two 75 year old patients;

  • ·      Patient A is diagnosed with prostate cancer with a PSA of 5000 and a Gleason Score of 4+5=9.
  • ·      Patient B has a PSA of 1.5 and Gleason is 3+3=6.

So in this case I would not recommend treatment for Patient B, I would repeat the PSA in 3-6 months and see how fast it’s progressing.

Patient A could benefit from local control of the prostate cancer, external beam Radiation treatment, then treatment of the any painful bone metastases.

Let’s confuse the issue, there is a third patient that has a PSA of 2.2 and a Gleason score of 4+5. He needs treatment.

Now back to the first recommendation, if you’re less than 75 years old then the data is insufficient. The USPSTF was comparing the validity of the PSA test. This is a subject that I will address in detail at a later date but it is my belief that the PSA test, although not perfect, is still currently the best test available. The report went on to say 12-13% of the PSA’s are falsely positive (we call it a false positive when a PSA test it considered positive due to it’s high value but is “proven” to be incorrect). Assuming this is true (again, I’ll address this issue later too), how do you prove it’s false. Normally the doctor will perform a Digital Rectal Exam (DRE) at the same time, this is used as secondary check (see link for more information). The more definitive test is a prostate biopsy. If the biopsy comes back negative then it’s assumed a false positive. I contend that, and I admit I have little proof other than my clinical experience, that 90% of these are bad or incorrect biopsy’s.

The newer report states that there is “no reduction in prostate cancer–specific mortality”. Assume that is true, that’s not the point, what about quality of life, would you rather die instantly of a massive stroke or heart attack or would you rather suffer with a painful debilitating disease eventually to succumb to the disease. I personally believe that early detection does increase life, the problem is when you dies and are known to have cancer, the doctor writes cancer on the death certificate. Less than 5% of people that die in a hospital ever get an autopsy. (this is the subject of a whole new blog).

The biggest problem I have with all this is in order to find out if you have an treatable form of prostate cancer you need to find it first. The best way is the PSA test. Does it have issues, yes, but the bigger issues are not the PSA test itself, but the biopsy and complications of treatment. The bottom line for most of our patients, is:

  • ·      Sure I don’t want erectile dysfunction, but I’d rather be alive.
  • ·      Sure I don’t want urinary incontinence, but I’d rather be alive.
  • ·      Sure I don’t want a rectal fistula, but I’d rather be alive.

So again, should you get a PSA screening, my answer is unequivocally, YES!

Friday, December 16, 2011

PSA testing

There have been a number of articles on the validity of the PSA test. Last Year, a Dr. Gifford Jones, a gynecologist practicing in Toronto, wrote an article published on the web site titled “Seven Things to Know About Prostate Cancer”. What makes a gynecologist an expert on a make urologic issue, I’m not sure, but that surely allows me, as a board certified medical specialist, to respond.


First of all, it was not Disraeli, who remarked, “there are three kinds of lies, lies, damn lies and statistics”, it is actually popularized by Mark Twain. No evidence of the quote can be found in any of Disraeli’s works and the first known appearance of this saying appeared years after Disraeli’s death. In this article Dr. Jones referenced an article from the New England Journal of Medicine that had just reported a European study that showed that this blood test cut the death rate of this disease by 20 percent. But then goes on to editorialize “But this impressive figure refers to a relative reduction in deaths” (Emphasis added). He continues on to quote figures that of those that received the PSA test, 261 died, compared to the 383 who received routine care. He then states; “A difference of 102 deaths out of 162,000 men isn’t as impressive”. I beg to differ, especially if your one of the 102 patients or a family member of one of those who didn’t die! The next paragraph is even more egregious, it states as a result of the PSA test 1,410 men have to be screened (by the PSA test), from that 48 of these men are treated, to prevent one prostate cancer death. The implication here is if you test 1,410 men, this will result in an additional 48 men being diagnosed with and treated for prostate cancer but 47 of those men will still be cured of their disease. That seems like you are saving the lives of 47 men out of every 1,410 who are tested. Now who’s playing with numbers? There are numerous problems here. First if all, if a patient has advanced cancer and dies, normally the cause of death listed on the certificate of death as cancer. Rarely does cancer kill the patient, it is normally complications of that cancer or the treatments used to keep them comfortable that kills them. Ultimately all of us die of cardiac arrest.


Dr. Jones’ treatment information is questionable at best. Radium seeds have NEVER been used for prostate cancer, the choices are Iodine, or Palladium and more recently Cesium has been introduced. Current protocols call for Radical Prostatectomy, External Beam Radiation or Radioactive Seeds, and/or Hormone therapy are the three primary treatment modalities. It is reasonable well understood by most physicians, which treatments are the most appropriate depending on the age of the patient and the diagnostic indicators. There are “newer” therapies, Cryosurgery, Hyperthermia, etc, etc, but the three above mentioned are still considered the primary options.


This is where Dr. Jones and I sort of agree. Marilyn Von Savant was once asked, is medicine an art or a science? Her response was “it was a science performed by artists”. Like most things, as long as humans are involved there is always some variability, in this case it is in determining how malignant the tumor is. But Dr. Gleason developed a method of grading the “aggressiveness” of prostate cancer. It has become a reliable indicator of aggressiveness of the disease and is used (along with the PSA) a one of the primary diagnostic indicators in determining which form of treatment is the most appropriate. Ironically, the late Dr. Whitmore, “a world authority on prostate cancer” allegedly died from metastatic prostate cancer. When a colleague of my partner asked what him what his PSA was, he responded, he didn’t believe in the PSA test!


“First, do no harm”. When you inject a patient, you do harm, it must, every young child cries when receiving a shot. Medicine should be looked at as a cost vs. benefit approach (when I say cost I don’t mean financial, although that seems to be entering into it more and more).


The one question left out of all these responses is quality of life. I’ve watched many men get worse and worse due to the progression of their prostate cancer eventually succumbing to it. When prostate cancer advances it spreads to local organs which are the bladder and colon/rectum, eventually metastasizing to the bones. It is a miserable/painful demise.


Yes, urinary incontinence is a side effect of treatment, typically but not limited to a radical prostatectomy. A rectal fistula can occur from radiation therapy if not done properly. All of these complication are almost certain if you decide not to be treated, eventually the cancer will spread from the prostate to the bladder and rectum causing these and all sorts of other complications, unless you die before they occur.


Ok, I was wrong when I said there was only one thing I agreed with Dr. Jones about, I partially agree with this point too, if you are confused about prostate cancer, get as much information as possible before treatment. There are lots of good websites that have good information on treatment options. I too cast a wary eye on statistics, but this is not a pattern of statistics.

The question, I assume, is, should you get a PSA test? My answer is unequivocally, YES!