Mike Glodé
| MIKE GLODÉ | |
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University of Colorado Cancer Center Denver, Colorado |
1. I approve because I think the discussions generated are healthy, and when the seminal studies were published earlier, they did not really get the public attention they deserved. The NEJM editorial "Screening for Prostate Cancer—The Controversy That Refuses to Die" was about as good a discussion as you can get.
2. Yes, with the caveat (re: prostate) that the follow-up may show more impact than we currently think for this slow-moving disease.
3. I think it is avoiding unnecessary morbidity. However, as with many, many things in oncology today, we really have to also begin to address cost/benefit in a forthright manner. Not to do so would be an abrogation of our responsibility to society as a whole, and like it or not, we cannot continue on the current path of increasing health care costs.
4. Not sure. I liked the idea that they had an outside group review their recommendations prior to their official release (although it did little to prevent the firestorm).
5. My continued belief is that we do NOT have a truly effective way of communicating the controversy BEFORE the blood is drawn or the rectal exam is done. I think that for high-risk patients (AA, first-degree relatives, BRCA2 families, etc) it is not controversial and I will simply continue to recommend screening. For "average risk" (which is everyone), I am trying to think of ways to do efficient pre-screening education. I did a non–IRB-approved "pilot study" in a group of twelve patients at a free screening clinic. I gave them a 5-minute lecture in groups of three or so in terms of what we know and don't know about screening and went over the PLCO and European data. Afterwards, two declined screening. I think I may try to get a video put together next, and maybe not participate in screening clinics unless/until patients have watched it. I would feel that is more ethical than blindly screening people who simply "believe" and have signed a bunch of paperwork they never really read.
Lee Ellis
| LEE ELLIS | |
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University of Texas MD Anderson Cancer Center Houston, Texas |
As a GI person, I do not have much exposure to discussions on prostate cancer. Frankly, I'm happy with the recommendations, as a 50+-year-old male who goes in for an annual physical….Although my PSAs have always been normal, I've always worried about a slightly elevated PSA and then the chase for some indolent cancer . . . this is not like the colon where a polypectomy removes the risk of the development of cancer…prostatectomy or radiation is, of course, a much more morbid treatment…if the science says "no screening," why argue with science? . . . As scientists, we either believe in science or we should not be doing science.
James Yu
| JAMES YU | |
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Yale Comprehensive Cancer Center Yale University School of Medicine New Haven, Connecticut |
1. Disapprove. PSA screening is a very complex issue, and a blanket statement about the lack of utility of PSA screening is inappropriate and dangerous. PSA screening provides useful information for an informed discussion of prostate cancer treatment with a patient's physician.
2. I think the panel ignored important observational data in the interest of only focusing on poorly performed randomized trials. They were very narrowly focused.
3. I think the core of the PSA decision is an over emphasis on randomized trials, even poorly run randomized trials, over obvious and strong epidemiologic data. The panel focused on what they thought was unnecessary morbidity. However, there was no oncologist or urologist on that panel as far as I can tell, and no one to tell them that surgery and radiation had progressed since the time of study accrual.
4. They should rely less on simplistic guidelines, and release a statement that recognizes the nuance involved when discussing screening results with men. They could also allow for the inclusion of epidemiological data showing that patients are less likely to die of prostate cancer in the modern PSA era, that there is a lower incidence of advanced disease in the PSA era—and they should include someone with clinical knowledge of the cancer in question.
5. I still encourage screening for all patients. I also encourage watchful waiting in favorable risk patients. I have a very good relationship with my patients – I give them my email address and cell phone number and encourage them to ask me questions. I have no incentive to overtreat (I am a salaried, academic radiation oncologist) and therefore I wholeheartedly encourage watchful waiting when appropriate.
