Comments on: Will patients accept the limitations of prostate cancer screening? http://www.kevinmd.com/blog/2009/04/will-patients-accept-limitations-of.html medical blog Sun, 22 Nov 2009 22:50:49 -0500 http://wordpress.org/?v=2.8.4 hourly 1 By: blacktag http://www.kevinmd.com/blog/2009/04/will-patients-accept-limitations-of.html/comment-page-1#comment-90723 blacktag Mon, 06 Apr 2009 04:05:00 +0000 http://clients.emmense.com/kevinmd/2009/04/will-patients-accept-the-limitations-of-prostate-cancer-screening.html#comment-90723 I am glad we agree on the thrust of the problem, but it is important that we are clear about where the problem lies.<br/><br/>Saying that it is a problem with the PSA test implies a technical problem, for which there can be a quick-fix solution. In any case, there is no better test in the horizon that will be subjected to equivalent screening trials.<br/><br/>It's important to look at the mirror and say unequivocally that the problem is us, not a test. Our flawed approach to radical surgery and RT makes it a lot more uncomfortable for urologists and radiation oncologists, armed with da Vinci and IMRT machines. I am glad we agree on the thrust of the problem, but it is important that we are clear about where the problem lies.

Saying that it is a problem with the PSA test implies a technical problem, for which there can be a quick-fix solution. In any case, there is no better test in the horizon that will be subjected to equivalent screening trials.

It’s important to look at the mirror and say unequivocally that the problem is us, not a test. Our flawed approach to radical surgery and RT makes it a lot more uncomfortable for urologists and radiation oncologists, armed with da Vinci and IMRT machines.

]]> By: Smokey http://www.kevinmd.com/blog/2009/04/will-patients-accept-limitations-of.html/comment-page-1#comment-90720 Smokey Mon, 06 Apr 2009 02:32:00 +0000 http://clients.emmense.com/kevinmd/2009/04/will-patients-accept-the-limitations-of-prostate-cancer-screening.html#comment-90720 Blacktag - I don't think we disagree. Clearly there are patients with aggressive prostate cancer who would benefit from aggressive treatment. The PSA is just not sensitive enough a test to distinguish between indolent and progressive disease. I wholeheartedly agree with your comments about the flawed approach toward localized disease. Incidentally, Dr. Hadley would also agree. Blacktag – I don’t think we disagree. Clearly there are patients with aggressive prostate cancer who would benefit from aggressive treatment. The PSA is just not sensitive enough a test to distinguish between indolent and progressive disease. I wholeheartedly agree with your comments about the flawed approach toward localized disease. Incidentally, Dr. Hadley would also agree.

]]> By: blacktag http://www.kevinmd.com/blog/2009/04/will-patients-accept-limitations-of.html/comment-page-1#comment-90719 blacktag Mon, 06 Apr 2009 01:16:00 +0000 http://clients.emmense.com/kevinmd/2009/04/will-patients-accept-the-limitations-of-prostate-cancer-screening.html#comment-90719 I would disagree with Kevin and Smokey. Clearly the main problem being highlighted by the screening trials is the tremendous *morbidity* that accompanies the interventions used for the "elevated" PSA, not the PSA test per se (while accepting that the QOL studies are not released, complications are unlikely to improve on historical results).<br/><br/>The problem cannot be the PSA test - a blood test doesn't harm per se. It is a flawed and aggressive approach that has been undertaken by urologists and radiation oncologists towards localized disease.<br/><br/>These came about because of multiple poorly designed trials and retrospective series of prostate cancer focusing on surrogate outcomes - usually PSA-based (biochemical relapse etc), lymph node metastases - rather than tangible clinical outcomes such as quality of life, cancer-specific survival and overall survival. Sure, these are difficult to do, but better to do them, than focus on noise. The only trial of primary treament was done in Sweden for example.<br/><br/>In fact, I think the message of the trials is loud and clear, and may actually be more important than what has been discussed, since it is not a message about screening. It is essentially saying that an aggressive *up-front* approach towards the "elevated" PSA is unlikely to be warranted, and is not associated with much benefit.<br/><br/>The conclusion I am drawing from the results is that deferred intervention/ surveillance, rather than upfront radical prostatectomy or RT, is probably the best approach if a screen-detected PSA is <10. If PSA is > 10, then a radical approach may be selected based on randomized data (NNT = 20). I would disagree with Kevin and Smokey. Clearly the main problem being highlighted by the screening trials is the tremendous *morbidity* that accompanies the interventions used for the "elevated" PSA, not the PSA test per se (while accepting that the QOL studies are not released, complications are unlikely to improve on historical results).

The problem cannot be the PSA test – a blood test doesn't harm per se. It is a flawed and aggressive approach that has been undertaken by urologists and radiation oncologists towards localized disease.

These came about because of multiple poorly designed trials and retrospective series of prostate cancer focusing on surrogate outcomes – usually PSA-based (biochemical relapse etc), lymph node metastases – rather than tangible clinical outcomes such as quality of life, cancer-specific survival and overall survival. Sure, these are difficult to do, but better to do them, than focus on noise. The only trial of primary treament was done in Sweden for example.

In fact, I think the message of the trials is loud and clear, and may actually be more important than what has been discussed, since it is not a message about screening. It is essentially saying that an aggressive *up-front* approach towards the "elevated" PSA is unlikely to be warranted, and is not associated with much benefit.

The conclusion I am drawing from the results is that deferred intervention/ surveillance, rather than upfront radical prostatectomy or RT, is probably the best approach if a screen-detected PSA is <10. If PSA is > 10, then a radical approach may be selected based on randomized data (NNT = 20).

]]> By: Smokey http://www.kevinmd.com/blog/2009/04/will-patients-accept-limitations-of.html/comment-page-1#comment-90711 Smokey Sun, 05 Apr 2009 19:41:00 +0000 http://clients.emmense.com/kevinmd/2009/04/will-patients-accept-the-limitations-of-prostate-cancer-screening.html#comment-90711 The problem with the comment that "few is in the eye of the beholder", is, of course, the problem of retrospection. Obviously, the "one" whose life was saved is pleased. but what about the (potentially) many who ended up having an unnecessary invasive procedure. Of course, they don't realize it was unnecessary - they are just relieved. Prospectively, you don't know which is which. As a 61-year-old physician, I have yet to have my PSA measured. If a better test comes along, I will consider it. I agree with Kevin that a better test will probably end the controversy.<br/><br/>By the way, The Last Well Person, by Dr. Nortin Hadler, has a good and controversial take on this subject. The problem with the comment that “few is in the eye of the beholder”, is, of course, the problem of retrospection. Obviously, the “one” whose life was saved is pleased. but what about the (potentially) many who ended up having an unnecessary invasive procedure. Of course, they don’t realize it was unnecessary – they are just relieved. Prospectively, you don’t know which is which. As a 61-year-old physician, I have yet to have my PSA measured. If a better test comes along, I will consider it. I agree with Kevin that a better test will probably end the controversy.

By the way, The Last Well Person, by Dr. Nortin Hadler, has a good and controversial take on this subject.

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