bye bye PSA...

[JumpingFrenchmn]

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http://nyti.ms/nqQH7a

 

[thesauce]

It may not be going anywhere for while. The recommendation is for healthy men. What exactly is meant by that? If someone has HTN, should that person be deemed "unhealthy" and get the test? What if they have a strong family history? Also, the fallout will be immense. They would essentially be replacing an established screening test with no screening (aside from DRE), which will be hard for many to swallow. On top of that, the legislation requires Medicare to pay for it regardless of these recommendations so there's no incentive to stop doing it...yet.

 

[G'ville Nole]

Remember the outcry when they recommended against mammography for women under 50? Same thing is likely to happen here.

I don't think anyone would debate that the USPSTF screening recommendations aren't based on a reasonable statistical analysis of the existing cancer screening and outcomes data. The problem is that cold, hard stats ignore the psychology involved with a cancer diagnosis. Patients can be told that we have to treat 50 prostate cancer patients to save one life, but I suspect what they ultimately come away with is "what if I'm that one?"

I seem to recall a recent study indicating that 3 normal PSA results in men aged 50-70 predicted an extremely low risk of prostate cancer mortality. This is a bit more analogous to the current cervical cancer screening recommendations (i.e. stop after 65 w/ 3 consecutive normals, and no abnormal for 10 yrs). I'm sure that data set is more limited, but if validated would make for a more nuanced and, umm, "politically viable" pronouncement than the current recommendation.

 

[deleted4401]

If followed, it would decimate most community doctors incomes....
S

 

[honger]

It may not be going anywhere for while. The recommendation is for healthy men. What exactly is meant by that? If someone has HTN, should that person be deemed "unhealthy" and get the test? What if they have a strong family history? Also, the fallout will be immense. They would essentially be replacing an established screening test with no screening (aside from DRE), which will be hard for many to swallow. On top of that, the legislation requires Medicare to pay for it regardless of these recommendations so there's no incentive to stop doing it...yet.

Wouldn't you be less inclined to screen and treat non-healthy patients?

 

[thesauce]

Wouldn't you be less inclined to screen and treat non-healthy patients?

Again, depends on what you mean by "non-healthy" patients.

Some treatments for prostate cancer, such as hormone therapy, are arguably easier to tolerate by older men and/or those with poor SHIM scores.

 

[deleted4401]

I think screening refers to the healthy. If people are unhealthy, i.e. Have life expectancies less than 10-15 years, they most certainly should not be screened. The vast majority of people with prostate cancer will not die of disease.

The problem with prostate cancer is That we can cure those that wouldn't die of disease, but can't cure those that will likely succumb to it.

 

[bronx43]

How this would be implemented would depend on individual primary care physicians, as well as what Medicare and private insurers do as far as coverage. Public outcries are public outcries. You'll get whenever you get rid of any item on the all you can eat medical buffet. But, obviously rationing is in the books for any sustainable medical system in the US, so people better get used to it.

 

[Carotenoid]

I don't think USPTF recommendations are followed that closely - esp. for "hot-button" issues that are widely publicized and emotionally charged for the patients. Just look at the breast cancer screening.

 

[bronx43]

I don't think USPTF recommendations are followed that closely - esp. for "hot-button" issues that are widely publicized and emotionally charged for the patients. Just look at the breast cancer screening.

Prostate cancer is nowhere near the "hot-button" issue that breast cancer is. When's the last time the NFL did a prostate cancer awareness week where all the players wore light blue shoes and ribbons?

 

[Gfunk6]

But, obviously rationing is in the books for any sustainable medical system in the US, so people better get used to it.

Very true. From the Rad Onc end, I think it would be prudent of us to embrace treatment efficiency to move away from (rightful) criticisms of radiation over-utilization. Therefore, hypofractionate (breast, prostate, bone mets) or use brachytherapy whenever is clinically appropriate. I've definitely started doing this and though I sometimes provoke raised eyebrows (esp. 8 Gy x 1 for bone mets, which I think should be the clinical standard of care without a GOOD reason), I believe I'm doing the right thing for my patients and specialty.

 

[deleted4401]

From: http://www.nytimes.com/2011/10/09/m...hpw&adxnnlx=1318442587-BQDxtm9WyFxlQXEXcH2 wg

“Imagine you are one of 100 men in a room,” he says. “Seventeen of you will be diagnosed with prostate cancer, and three are destined to die from it. But nobody knows which ones.” Now imagine there is a man wearing a white coat on the other side of the door. In his hand are 17 pills, one of which will save the life of one of the men with prostate cancer. “You’d probably want to invite him into the room to deliver the pill, wouldn’t you?” Newman says.

Statistics for the effects of P.S.A. testing are often represented this way — only in terms of possible benefit. But Newman says that to completely convey the P.S.A. screening story, you have to extend the metaphor. After handing out the pills, the man in the white coat randomly shoots one of the 17 men dead. Then he shoots 10 more in the groin, leaving them impotent or incontinent.

Newman pauses. “Now would you open that door?” He argues that the only way to measure any screening test or treatment accurately is to examine overall mortality. That means researchers must look not just at the number of deaths from the disease but also at the number of deaths caused by treatment.

 

[Gfunk6]

Here is ASTRO's official position on the subject. Bottom line: Leave the decision up to the physicians and their patients.