A man in his early 40’s diagnosed with Gleason’s 7 prostate cancer with normal gland on exam and slightly elevated PSA.

My dear buddy Jo An Baldwin Peters made a comment on one of the posts yesterday and mentioned that her husband needed a MRI. They live in Canada and she related that the MRI had been scheduled some time in 2013. She mentioned, “Wait until the U.S. gets health care.”

I mention this to say that it is difficult to get a PSA approved in the U.K. because of the criteria that must be met by the family M.D. to justify the test. Keith Cass makes this point on his website www.theredsock.co.uk

So enter a healthy asymptomatic male in his early 40’s to my office last week who because his father had prostate cancer, his family doctor ordered a PSA. He is in turn sent to me and has a normal rectal exam. We elect to do the prostate biopsy and it shows 5 of 12 cores positive for Gleason’s 7 prostate cancer.

Is there anyone in the audience who would argue that he should not have had a PSA drawn? Or that the above scenario will have no impact on his longevity had it not been discovered? Or that, “Well yes it found something this time or this patient, but you can’t do that on everybody. It would be too expensive to test so many people only to find this guy every so often. (You know that is the argument.) Wonder what this particular patient would say to that argument? What do you want for your father, husband or brother.

What say you?

From a CME test I took earlier today…

Screening for Prostate Cancer: A Review of the Evidence for the U.S. Preventive Services Task Force.

Chou R, Croswell JM, et al: Ann Intern Med; 2011;155 (December 6): 762-771

Objective: To review the results of recent PSA studies and to summarize this evidence.

Design/Methods: A systematic review (SR) and meta-analysis (MA) of the data were performed for randomized, controlled trials (RCTs) and cohort studies looking at PSA screening and treatments for prostate cancer (PC). The study focused on 4 questions: does PSA screening decrease mortality, what are the harms of screening, what are the benefits of treating early or screened PC, and what are the harms of early treatment?

Results: Conflicting results on PC mortality were seen from 3 specific RCTs, 2 showing benefit and 1 no benefit. Serious infection or urinary retention from biopsy occurred in 1 in 200 men. A 6% absolute survival benefit from radical prostatectomy (RP) versus watchful waiting (WW) was reported from a high-quality RCT, and cohort studies reported consistent benefit to RP and radiation therapy (RT) over WW. Harms from these treatments were erectile dysfunction (ED) in 1 of 3 men after RP, in 1 of 7 men after RT, and incontinence in 1 of 5 men after RP.

Conclusions: Current population-based PSA screening detects more early prostate cancer but results in a small, if any, increase in survival. There are measurable risks of biopsy and significant harms of early treatment.

Reviewer’s Comments: The U.S. Preventive Services Task Force PSA recommendations have sparked a controversy over PSA testing that has forced many stakeholders, including physicians, patients, and ultimately policy makers, to form an opinion on the future of men’s health care. This review presents a well-developed summary of current evidence on PSA screening and standard treatments for PC. What is not immediately clear is how this synthesis should lead to a recommendation against all future PSA screening, as advocated by the task force. Arguments against the task force’s extreme position abound. Final decisions regarding mortality from screening tests should not be made based on early reporting, yet the RCTs included here are only at 9 to 10 year follow-up for a disease with up to a 25-year progression. It may also be inappropriate to combine the data from these trials, as they are extremely heterogeneous in the screened and “unscreened” populations. The number needed to treat cited (48) for survival is likely too high. Estimates from the European Randomized Study of Screening for Prostate Cancer are 12 to 20, and the U.S. Prostate, Lung, Colorectal, and Ovarian subgroup analysis suggests 5. Finally, even without an overall survival benefit, many would argue that the reduction in metastatic and local disease morbidity has provided a significant benefit to the way men currently experience prostate cancer. We should certainly accept the current limitations of PSA, as laid out extremely well by the task force. However, rather than abandon it, we should pursue improvements in its current application.(Reviewer–Steven E. Canfield, MD).

 

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