Louis Potters
| LOUIS POTTERS | |
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North Shore-LIJ Health System Hofstra North Shore-LIJ School of Medicine New Hyde Park and Hempstead, New York |
The issue is that we and our patients are reluctant to not be treated. There is a sense of entitlement toward therapy once given a diagnosis of "the big C." And that allows patients to choose from protons to robots.
The task force data are actually quite clean but do not have enough power to dissect disease risk. Of the three categories of patients (those who will die no matter what is done, those for whom treatment is a waste of time since the disease is indolent or their life expectancy falls short, or lastly, those for whom therapy is effective), it is better to select therapy against the disease risk one falls into (thus allowing research on new and other markers of disease risk). Ergo, from the patient's or the physician/researcher's perspective, the task force leaves us short: we will never know what we do not learn to know about.
If "we" could accept active surveillance for the majority of low-risk patients, then we allow the disease to "declare" itself over time and thus avoid the harms of treatment in potentially many men. That serves the recommendations of the task force (avoiding harm of treatment) as a trade-off for avoiding the harm of biopsy.
Responding to Dr. Potters
| MIKE GLODÉ | |
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University of Colorado Cancer Center Denver, Colorado |
Louis has said it well. I have blogged on the challenges at my blog, prost8blog.com. The patient responses are interesting (and predictable). In my view, the problem with surveillance is the emotional burden (never mind the risks of continued biopsies, etc, and lack of level 1 evidence for this approach vs treatment in terms of survival—we failed to recruit successfully to Lawrie Klotz's randomized trial, as did everyone else...). No one really wants to "just watch" a cancer grow, even if the risk of metastasis is finite and small. The happiest are those who don't know they have indolent disease or have none at all, but our current technology can't separate them out and keep them from finding out.
David Crawford
| DAVID CRAWFORD | |
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University of Colorado Health Sciences Center Denver, Colorado |
In 1989 we started Prostate Cancer Awareness Week to educate men about prostate cancer and promote early detection because it was that year that the disease became the number-one cancer diagnosed in American males and the second leading cause of death. We had no idea whether screening would work, but we did know that the majority of cases of the disease diagnosed then were advanced and incurable.
As chairman of this group since inception, I realized that we had no level 1 evidence to support early detection. Our event was very successful and remains the largest screening event for any cancer in the world. The number of cases of advanced disease plummeted. We found more early cancers, and the pendulum began to swing too far the other way: we were finding many cancers that appeared to be non-threatening, and there was a masterful marketing scheme by a company selling so-called robots and a proliferation of expensive radiotherapeutic techniques. And rather than focus on who needs to be treated, we entered an era of overtreatment in some men.
At the same time an ongoing US trial called the PLCO demonstrated that screening did not alter mortality. I was the principal investigator for one of the ten US sites. This trial was ignored by the mainstream, while a weakly positive trial from Europe was embraced. So the US Preventive Services Task Force have reviewed the data, including the current report which concludes that screening is not appropriate.
So what should we do? The truth lies somewhere in between. We should not return to 1989 when advanced disease dominated; rather, we should prudently screen men and separate diagnosis from treatment. We should strive to determine who could benefit from treatment. We need new markers of aggressiveness. We need to resist the marketing strategies of companies who mislead the public. We should acknowledge the very thoughtful conclusions of this task force and respond during this time of analysis with a plan to evaluate how to somehow eradicate the pain and suffering from this disease. We need to alter the death rate. We should work with organizations like the AUA and others to achieve this goal.
Lodovico Balducci
| LODOVICO BALDUCCI | |
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H. Lee Moffitt Cancer Center and Research Institute Tampa, Florida |
1. I wholeheartedly approve. The guidelines have never been evidence-based, and the evidence is not there to support them. In the meantime, there is a lot of evidence of the damage done by treating people who don't need treatment.
2. I don't know of any PSA guidelines that are evidence-based. The mammography guidelines are based on some evidence for women aged 50+, but a number of questions are still open—especially whether you need to screen every 2 years, whether in older women (70+) mammography or other imaging techniques are superior to physical examination of the breast by a professional.
3. Avoiding unnecessary morbidity is the main reason. Avoiding unnecessary costs is also important. In the management of prostate cancer, we waste billions of dollars every year doing a lot of damage and showing no evidence that we are doing any good.
4. The USPSTF has the best approach and should not improve on anything.
William Hoskins
| WILLIAM HOSKINS | |
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Department of Surgery Memorial Sloan-Kettering Cancer Center New York, New York |
I do think the recommendations were based on a review of available data, but the decision to recommend changes in the screening criteria are based on the rather subjective interpretation that the side effects of the screening (anxiety, negative biopsies, etc) are harmful to the patient. In both cases, however, there will be some early cancers not picked up that might have otherwise been diagnosed early. While this may not be sufficient to cause a significant shift in survival, for the individual patient, they may be significant. My institution and the experts in breast and prostate cancer here have elected not to change their recommendations—ie, annual mammograms for women after age 40 and annual PSA until age 70.
