This month we asked ONCOLOGY's Editorial Board to informally weigh in on the US Preventive Services Task Force's recommendation against the routine screening of healthy men with the prostate-specific antigen (PSA) test. We asked them to answer the following questions—or provide a free-form response as they wished:
1. Do you approve or disapprove of the new guidelines and why?
2. Do you believe the recommendations, both for PSA screening and mammography, were valid and evidence-based?
3. What do you think is at the core of the PSA decision—reimbursement, avoiding unnecessary morbidity?
4. How do you think groups like the USPSTF could improve on their approach to formulating guidelines for screening tests?
5. How will this affect what you tell patients—both high-risk and not?
Thomas Marsland
| THOMAS MARSLAND | |
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Florida Oncology Associates Orange Park, Florida |
This is a very emotional issue. Any time a group claims less screening is good, I always take it with a grain of salt—yet the data certainly seem to support that generalized screening with PSA may not impact survival in the general population. We have recently been down this same path with mammography, so the issues become: who does benefit from screening, and where is it beneficial?
We need better ways to determine tumor biology—which tumor is likely to sit there for years, and which tumor is going to be more aggressive. The life expectancy of the person being screened is also a factor. I completely agree that for patients with limited life expectancy due to another comorbid condition, screening makes little sense. Yet if you are looking at an active, healthy 70-year-old with a life expectancy of 20 or more years, I certainly could make an argument to screen that person. So the issue of subpopulations may very well have impacted these studies. I honestly believe reimbursement is at least partially behind some of these recommendations.
The bottom line is that men are still dying from prostate cancer, and no cancer was ever cured by ignoring it. I would counsel men with life expectancies of 10 years or more to be screened, and continue eagerly to wait for the molecular marker that will tell us which cancers will sit there for 10 years and which ones will behave more aggressively (but even then you'll never find them if you don't look for them...).
Responding to Dr. Marsland
| FRANCIS ARENA | |
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Arena Oncology Associates Great Neck, New York |
Perfectly stated. I fully agree with Thomas Marsland.
Responding to Dr. Marsland
| ALLEN YEILDING | |
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HOAA, LLC Birmingham, Alabama |
I agree with Dr. Marsland, and basically feel screening mammograms and PSA remain important in early diagnosis and are associated with better prognosis; that it is difficult to quantify the cost of evaluation and management of supposed subgroups who had no benefit from earlier detection, and the savings created by improving outcomes. There are bigger and less politically volatile fish to fry, as both of these procedures also enhance a person's participation in their own well being, instead of the negative of being told the screening isn't "cost effective."
Responding to Dr. Marsland
| CHARLES PENLEY | |
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Tennessee Oncology Nashville, Tennessee |
I think that Tom Marsland accurately summarized my take on this. The USPSTF is correct as far as it goes. However, there are probably subgroups that will benefit, and identifying them is the trick. Note that they didn't say we shouldn't treat prostate cancer—they just said that there isn't evidence that screening some groups of asymptomatic men results in improvement in survival, and may contribute to unnecessary morbidity. Symptomatic men, or men who are diagnosed by other means, are off the table and not part of this discussion.
The problem with this sort of declaration is that it is often handled poorly. Recall the mammogram issue. The pronouncement came from on high, with no antecedent discussion with other stakeholders. This resulted in an outcry from every corner of the globe. If they had convened a summit, presented the data to all the recognized experts and groups, and then come out with a consensus statement, it would have been received far better by the public. However, I get the sense that this issue was handled in much the same way as the mammography recommendations.
Are we currently overdoing it? You betcha! I've seen many men, well into their 80s, getting their routine PSA screening, then getting the "full monty" treatment when a small asymptomatic prostate cancer is diagnosed. Did that help them? Hard to see that it could.
As with most disagreements, the truth is usually somewhere in the middle. In time, reason will prevail, and we will likely settle in to a "new norm" with respect to screening.
