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When Is Screening Excessive? Researchers Offer Some Practical Advice Amidst PSA Controversy Cont
Such general recommendations ruffled plenty of providers.
“A lot of primary-care physicians were upset, myself included,” said Richard Hoffman, MD, a staff physician at the Albuquerque, NM, VA Medical Center. Due to evidence supporting a “small benefit,” Hoffman objected to the sweeping guidelines. “Patients should be able to make that decision for themselves.”
Toward that end, Hoffman stressed the importance of decision aids to help men “clarify their values.” An informed decision is imperative but not always easy, because doctors might be limited by time or unaware of the most recent data, he said. These tools help provide the patient and physician with a “much more focused and much more efficient use of time.”
The American Cancer Society advocates a similar solution: “Because of the uncertainties, risks and potential benefits of prostate cancer screening, there is an ethical mandate to provide men who are considering screening with the opportunity to engage in an informed, decision-making process. Because of the complexity of the decision and the importance of individual values, men should have the opportunity to be assisted by a health professional in reaching this decision,” the organization states in its 2010 guidelines on the subject. “Because there is now an established body of evidence supporting the value and effectiveness of decision aids in facilitating informed decision-making, the availability and use of such aids should be promoted.”
The American Cancer Society provides such an aid, as do other organizations, including the Mayo Clinic and Centers for Disease Control and Prevention.
In the meantime, both Walter and Hoffman explain that certain cancers require rethinking – they aren’t all necessarily problematic. “Thirty percent of all men over 50 have microscopic prostate cancers that never are going to cause any problems,” Hoffman said. The PSA testing “is good at finding these cancers that we don’t need to find.” But, until more sophisticated testing becomes available, it’s “by default the best we have.”
While diagnoses of prostate cancer have spiked since the introduction of PSA testing — from 9 percent in 1985 to 16 percent in 2007 — most men diagnosed with prostate cancer die from other causes, Hoffman writes in an article published last fall in the New England Journal of Medicine.3
Meanwhile, a huge percentage of men who are diagnosed with prostate cancer undergo treatments laden with substantial risks. About 75% of men diagnosed with prostate cancer, as a result of PSA testing, were treated with surgery or radiation, according to a 2009 report that Hoffman co-authored in the Journal of the National Cancer Institute. Five years after surgery, nearly 80 percent of men suffered from erectile dysfunction. Among those treated with radiation, roughly 64 percent reported erectile dysfunction.4
Walter’s advice? Proceed with caution and always consider the individual needs of the patient.
“Think about the life expectancy of the man that you’re considering screening,” she said. “If they have a lot of other serious medical issues, screening them for PSA is just going to be harmful without benefit.” If the patient is strong and healthy, “this is where you really have to talk to the man about his concerns about prostate cancer” and the side effects of the test.
Bottom line: “PSA screening should not be in the same realm as things we do for public health,” like routine immunizations, she said. If test results turn out abnormal, “then you’re left to worry about it and wring your hands about it.”
For now, Hoffman finds some hope in a new approach to treatment called “active surveillance.” Instead of surgery or radiation, this method follows men’s progress through PSA tests and biopsies. “You’re saving a substantial proportion of men all the risks, costs and harms of treatment” while still responding to the diagnosis, he said.
“No one really likes to be told, ‘We’re just going to ignore it.’”
1: So C, Kirby KA, Mehta K, Hoffman RM, Powell AA, Freedland SJ, Sirovich B, Yano EM, Walter LC. Medical Center Characteristics Associated with PSA Screening in Elderly Veterans with Limited Life Expectancy. J Gen Intern Med. 2011 Dec 17.[Epub ahead of print] PubMed PMID: 22180196.
2. Zeliadt SB, Hoffman RM, Etzioni R, Gore JL, Kessler LG, Lin DW. Influence of publication of US and European prostate cancer screening trials on PSA testing practices. J Natl Cancer Inst. 2011 Mar 16;103(6):520-3. Epub 2011 Feb 28. PubMed PMID: 21357307.
3. Hoffman RM. Clinical practice. Screening for prostate cancer. N Engl J Med. 2011 Nov 24;365(21):2013-9. Epub 2011 Oct 26. Review. PubMed PMID: 22029754.
4. Potosky AL, Davis WW, Hoffman RM, Stanford JL, Stephenson RA, Penson DF,
Harlan LC. Five-year outcomes after prostatectomy or radiotherapy for prostate cancer: the prostate cancer outcomes study. J Natl Cancer Inst. 2004 Sep 15;96(18):1358-67. PubMed PMID: 15367568.
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