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Friday Feedback: Do Docs Know Best for PSA Screening?

Friday Feedback: Do Docs Know Best for PSA Screening?

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This edition of Friday Feedback comes from the archives. Every year at this time, MedPage Today‘s writers select a few of the most important stories published earlier in the year and examine what happened afterward. One of those original stories, which appeared April 19, is republished below; click here to read the follow-up.

Earlier this week, the U.S. Preventive Services Task Force (USPSTF) released an updated recommendation supporting individualized decision-making for PSA-based prostate cancer screening among men ages 55 to 69. Five years after their previous statement that recommended against routine PSA screening for men of any age, the updated draft better aligns with guidances from the American Urological Association (AUA) and the American Cancer Society (ACS), which promote discussion-based screening.

MedPage Today spoke with leading experts in the field, many of whom see the USPSTF update as a tool to help them deliver better care to patients.

To what extent does this recommendation now match what has evolved in routine practice since debate erupted over PSA screening?

Howard Sandler, MD, Cedars-Sinai Medical Center: The new recommendation is more consistent with other organizations that have generally recommended an individualized discussion between patient and physician. It seems to be pretty consistent with the AUA’s.

David F. Penson, MD, MPH, Vanderbilt University Medical Center: This puts the USPSTF in line with recommendations from most other major specialty societies and advocacy groups. This is good because the earlier recommendation against screening from the USPSTF made it difficult for primary care providers to figure out whether or not to screen men for prostate cancer, which resulted in a drop in screening and new diagnoses of prostate cancer, which may have some very negative effects over time.

Alexander Kutikov, MD, Fox Chase Cancer Center: The recommendation is now very much in line with current sentiments of most urologic oncologists. Decision-making regarding PSA screening must be thoughtful and nuanced. Although the concept of more thoughtful screening is a top-of-mind concern both for primary physicians and subspecialists, benefits of PSA screening exist. Yet, because not all patients stand to benefit, decisions must be individualized.

William Oh, MD, Icahn School of Medicine at Mount Sinai: Many primary care physicians have stopped routine PSA screening based on the USPSTF recommendations, but the ACS, AUA, and ACP have always suggested at least a discussion with patients about the pros and cons of screening. Alignment of these recommendations will allow better counseling to patients, particularly high-risk patients, but also to non-high-risk patients who may still get a PSA but not necessarily treat a low-grade cancer.

David Crawford, MD, University of Colorado Denver: There needed to be a change in early detection. There is no question that we were over-diagnosing and over-treating any man. The current correction is appropriate but that does not totally reflect practice.

Paul Turek, MD, The Turek Clinics: It’s heartening to hear that the Feds have backed off from their extreme statement that no PSA screening for prostate cancer be done in the U.S. to acknowledge that at-risk men (by age, ethnicity, or family history) should consider screening. As urologists, we thought we were “losing it,” but in fact it is now clear that we aren’t.

Sam Chang, MD, MBA, Vanderbilt University Medical Center: This is an important step to providing patients first, important information and second, the opportunity to participate in decision-making that may affect their livelihood.

Kevin T. McVary, MD, Southern Illinois University School of Medicine: The similarity between the USPSTF update and AUA guidelines are now very striking. The updated guidelines from the AUA were immediately embraced by urologists and other cancer specialists across the country. It was notable that in those adhering to the previous USPSTF PSA recommendations (now jettisoned) had dialed back on PSA screening too harshly; thus it will be interesting to see if these clinicians will adopt these newer suggestions from the USPSTF on PSA.

What is your recommendation to asymptomatic, average-risk men ages 55-69?

Turek: As a urologist in the trenches, I follow the AUA recommendations that men ages 55-69 should have an informed discussion of the risks and benefits of PSA screening and then decide for themselves whether they do it. I treat this issue just like I would when I am consenting a patient for a surgical procedure. It’s their decision and they need the information to make the right choice for themselves.

Philippe E. Spiess, MD, Moffitt Cancer Center: My recommendation is to discuss the merits and drawbacks of screening with a PCP and local urologist as it has been shown to detect prostate cancer at an earlier stage with an imparted curative potential.

William J. Catalona, MD, Northwestern Medicine: I would encourage asymptomatic, healthy men ages 55-69 to have an annual PSA test and a digital rectal exam to screen for prostate cancer.

Chang: The decision for initial PSA screening depends on a multitude of factors including age, race, family history, and overall health. An important part of the discussion is that initial PSA screening does not mandate more aggressive evaluation or biopsy or even repeat PSA’s. But I do tell patients it is another piece of information in their overall health management.

Oh: I make sure to emphasize that PSA screening does not necessarily mean that all prostate cancers need treatment. Active surveillance is a reasonable and safe option for men with low-grade cancers who are unlikely to benefit from surgery or radiation. However, PSA screening can pick up more lethal cancers that may be cured if caught early.

Sandler: I generally discuss the pros and cons of screening. In my experience, most men will choose to get the PSA test and thus would like to know more about their risk of cancer, to help them make an informed biopsy or treatment decision.

Kutikov: I liken PSA screening to purchasing an insurance policy. For some men this can be an “expensive” proposition that is not worthwhile, while for others screening can be a very wise investment. Ultimately, whether or not to be screened is based on each individual’s risk tolerance and preference. I encourage patients to educate themselves about the issue of screening, as it is quite complex.

How valuable are recommendations like this that just leave it up to patients and doctors to discuss, particularly since in practice most patients just go along with what their doctors advise?

Turek: These kinds of recommendations have great value nowadays because medicine is changing. It’s becoming more offensive than defensive in nature. Patients have a massive trove of information available to them on any medical issue and they are far more educated consumers of healthcare. They ask better questions and make better decisions. More and more, medical providers are viewed as consultants rather than as classic “patrons” of medicine.

Catalona: Most patients say, “What do you recommend, Doctor?” and then follow that recommendation. Therefore, the new USPSTF draft recommendation is somewhat useful in that they do not convey the same message as their 2012 recommendation. The new recommendation will now compel PCPs to at least discuss PSA screening with their patients, which will be burdensome to them, but many will probably discourage it. You must admit, the wording of the new Task Force recommendation could hardly be called a ringing endorsement.

Oliver Sartor, MD, Tulane Medical School: Discussing the “pros and cons” of PSA testing is good medicine but I do have a concern that a thorough discussion on this point is not easy and may not fit within the time allocated for a typical visit between a patient and internist. De facto, I think the patients will simply ask, what does the doctor recommend. Regardless I welcome the new recommendations that prefer this to be part of individual decision-making instead of a blanket “do not screen.”

Scott Eggener, MD, University of Chicago Medicine: Unfortunately, given the time constraints in a primary care clinic, it is not practical to have a thorough and detailed discussion with every single man. It is imperative for the research and clinical communities to develop comprehensive educational tools for men to learn more about screening.

Loeb: I believe that the new recommendations are a step in the right direction toward patient-centered care. In the past, many men were not told about PSA screening at all, so were not given the opportunity to participate in the decision. Screening has benefits and harms but the exact ratio of benefit to harm depends on patient preferences, so it is important that patients are told about the test and given the opportunity to participate actively in these decisions, which have significant implications for their health.

Oh: It remains a challenge to have PCPs and urologists discuss PSA screening in short routine visits. However, with a blanket recommendation against screening, no discussion of any kind occurs, and I believe that was the wrong approach. Patients can process the pros and cons if given adequate information and if they understand that even a diagnosis of prostate cancer may not need treatment in all circumstances.


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