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from Medscape.com

BOSTON — Physicians who routinely treat prostate cancer are “very likely” to undergo PSA screening themselves or recommend it to immediate family members, concludes a survey-based study presented here at the American Urological Association (AUA) 2017 Annual Meeting.

In total, 784 (90%) of the 869 physician respondents endorsed past or future screening for themselves or for relatives.

The survey respondents were mostly urologists (83%) and mostly came from North America (68%), as well as Central and South America, Europe, Australia, and New Zealand.

Less overwhelmingly, only 61% of the 807 male respondents had personally undergone PSA screening. However, 94% of the “screen eligible” men said they had taken a PSA test, clarified lead study author Christopher Wallis, MD, from the University of Toronto, Ontario, Canada.

Awkwardly, Dr Wallis did not know the age the AUA recommends most men start screening, when asked by a reporter. He guessed 50 years of age. “Fifty-five,” quietly said Stacy Loeb, MD, from New York University, New York City, who moderated the press conference.

Dr Wallis pointed out to Medscape Medical News that the survey is international and that, although the AUA recommends screening from age 55 to 69, the NCCN recommends screening from age 45 to 75, and the EAU recommends screening from 50 until life expectancy is less than 10 to 15 years.

Dr Loeb was loud and clear about the new results: “We can see that the doctors who manage prostate cancer really do practice what they preach, and choose PSA screening for themselves,” she said in a meeting press statement.

In the survey, 82% of the 807 male physicians also said they planned to have a PSA test in the future.

The women were less enthusiastic: Only 69% of the 62 female physicians had recommended PSA testing to immediate family members.

But the study has a methodological limitation: it contains exclusively self-reported behavior. “We don’t know if the men who said they got PSA testing actually got PSA testing,” Dr Wallis admitted.

Furthermore, “these results may be unreliable,” Dr Wallis told reporters.

“We don’t know if the men who said they got PSA testing actually got PSA testing,” Dr. Christopher Wallis added.

 He explained that physicians have been shown in a previous study to recommend different treatments than they would choose for themselves ( Arch Intern Med. 2011;171:630-634). The study was widely reported at the time, including by Medscape Medical News.

There is also a “discrepancy” between what physicians may recommend to one individual patient and what they recommend in general for a population of patients, according to other research, Dr Wallis said, citing other research.

 He said his team employed the “physician surrogate method” to “try and get around these issues.” Their methodology called for posing both direct and hypothetical questions to allow for a fuller range of responses. This method has, for example, been used to interview physicians about lung cancer preferences, he explained.

In the new survey, the male respondents were directly asked: “Have you been screened, and will you be screened?” If a man was not of screening age, the question was, “Do you plan to get screened?”

Women respondents were asked what they recommended their first-degree relatives (husbands, fathers, brothers, etc) do about PSA testing.

The study has limitations in addition to self-reporting. First, the authors do not know the response rate. “The organizations that distributed the survey wouldn’t tell us,” said Dr Wallis.

Second, the respondents were predominantly urologists. The responses may have differed with more oncologists, he suggested.

The purpose of the survey was to examine what motivates the recommendation for PSA testing from specialists.

“You could say that, in theory…a specialist may recommend screening to identify a cancer because that drives patients to them,” which is a financial motivation, but the results suggest these professionals are motivated instead by their trust in the PSA test, added Dr Wallis.

Finally, the survey also asked physicians whether they were diagnosed with prostate cancer and, if so, what treatment they chose.

Thirty men responded affirmatively: they had prostate cancer and had been treated. Similarly, 16 women responded affirmatively, speaking on behalf of relatives they had advised.

Specialists tended to get treated by their fellow specialists: “Urologists choose surgery, radiation oncologists choose radiation,” said Dr Wallis.

That is, 64% of the responding urologists received a radical prostatectomy and 83% of radiation oncologists underwent radiation therapy. There was a significant correlation between specialty and treatment (P = .001).

These treatment preferences are concordant with other research, emphasized Dr Wallis. That concordance, he said, might bode well for the accuracy of the PSA portion of the survey.

“Perhaps people are responding in a way that is reliable for our other question,” he said hopefully.

American Urological Association (AUA) 2017 Annual Meeting: Abstract PD07-07. Presented May 12, 2017.

Follow Medscape senior journalist Nick Mulcahy on Twitter: @MulcahyNick

For more from Medscape Oncology, follow us on Twitter: @MedscapeOnc

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This is actually quite informative. I put this together in 2011.  I hope you enjoy and possibly share with someone newly diagnosed.

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Urology Times Opines on the Subject

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The following is a comment to a previous post- Who regrets prostate treatment worse…

I did my due diligence after diagnosis at age 54 and decided on surgery first, salvage radiation in case of recurrence. Because I was well informed, my oncologist/surgeon was extremely honest and blunt. With my high PSA (40.98) and short doubling time he would be performing a non-nerve sparing Laparoscopic radical prostatectomy. This would result in no possibility of spontaneous erections following surgery. He would do his best to preserve continence. And if he couldn’t get a good ‘feel’ through the Laparoscopic tools, he would cut me open and ‘gut me like a fish’ to ensure the best possible outcome… life. Surgery was performed in November of 2008.
It took 3 months to get continence back. There have been no erections, even using trimix.
In June of 2011 my PSA started to rise, and in June of 2012 I underwent 40 radiation treatments. Both my primary oncologist and radiation oncologist explained the probable loss of continence and probable chronic colitis following radiation. The only adverse reaction is chronic colitis, but I am still in remission.
I do not regret having surgery, radiation, or the 6 months of hormone therapy post surgery. Based on the aggressiveness of my cancer I would probably be dead without all of the therapies. It’s important knowing all possible outcomes (death, complications from infection and scarring, incontinence, and erectile dysfunction) to make a decision that is right for you.
I have an acquaintance who is dying from aggressive prostate cancer. He was diagnosed with late stage cancer at 64, after not seeing a doctor for 15 years. For anyone in remission, no matter what symptoms we have as a result of treatment, those symptoms are a cakewalk compared to what my acquaintance is going through.

Something to think about.

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Ben Stiller’s misguided prostate cancer recommendations aren’t based on evidence-healthnewsreview.org

No it is based on examining the risks of the disease and the risks of the treatment and making a decision he felt was best for him. Regardless of your position on Mr. Psa 30,000 men a year die of prostate cancer. How is that?

Kevin Lomangino is the managing editor of HealthNewsReview.org. He tweets as @Klomangino.

Comedic actor Ben Stiller clearly had the best of intentions when he decided to write about his experience with prostate cancer and urge men to get a prostate specific antigen (PSA) test starting at the age of 40 – advice which contradicts the guidelines of all major professional organizations.

I admire Stiller’s intention to help out help out his fellow man, and I am glad to hear that he’s apparently doing well and satisfied with his treatment choices. I also applaud Stiller for acknowledging the controversy surrounding PSA testing with the following:

The criticism of the test is that depending on how they interpret the data, doctors can send patients for further tests like the MRI and the more invasive biopsy, when not needed. Physicians can find low-risk cancers that are not life threatening, especially to older patients. In some cases, men with this type of cancer get “over-treatment” like radiation or surgery, resulting in side effects such as impotence or incontinence.

That’s important context that’s often missing from similar celebrity health stories — and he also tells men to have a discussion with their doctors about the test. That’s certainly the best way for men to sort through their options and make an informed choice.

My problem with Stiller’s piece is that it makes a number of false or misleading assertions and fails to accurately reflect the evidence on prostate cancer screening. And because Stiller is smart, persuasive, and famous, his skewed piece may do a great deal of harm to men who may be led astray by his faulty reasoning.

NO PROOF that a PSA test saved Ben Stiller’s life

The most glaring problem with Stiller’s argument is that it’s built on a false assumption. He says, “Taking the PSA test saved my life. Literally. That’s why I am writing this now.”

He can’t say that with any certainty.

The facts are these: Prostate cancers vary in their aggressiveness, and some very aggressive cancers will prove fatal despite early detection and treatment like Stiller received, whereas the majority grow slowly and might never pose a problem to the patient. Stiller says his cancer had a Gleason Score of 7, but doesn’t offer full details about his case that would allow experts to assess the likelihood that he’d benefit from prostate removal. Even with those details, it would be impossible to know for certain whether his cancer would have spread or not.

For that reason, no one-including a celebrity with greater-than-normal access to top-notch healthcare–can say whether the test saved his life, or merely detected a cancer that could have been monitored and might never have bothered him.

Here’s how oncologist Vinay Prasad, MD, MPH, explained the flaws in Stiller’s logic to me:

Before embarking on any screening test, a physician MUST council a patient about harms of screening, including false positives and overdiagnosis–where a real cancer is found and treated, but it would not have caused the person problems. Ben Stiller’s strong faith that the test “saved his life” is incompatible with a true understanding of overdiagnosis. If he really understood overdiagnosis, he would understand that he could not say this definitively. Gil Welch has shown that often most people with breast cancer diagnosed by screening cannot claim to have their life saved. The same principles that apply in this study also apply to prostate cancer, and no person whose cancer was found by PSA screening can say definitively, “The test saved my life.”

HealthNewsReview.org contributor Douglas Campos-Outcalt, MD, agreed that the evidence cuts against Stiller.

When someone says “Taking the PSA test saved my life,” they have over a 95% chance of being wrong. There is a spectrum of aggressiveness in prostate cancers. The vast majority detected by screening are not aggressive and screening does more harm than good in these men. The most aggressive forms are not helped (usually) by screening because they are too aggressive and are not asymptomatic long enough to be detected by screening. The moderately aggressive tumors are the only ones that can benefit from screening and the unusual man who has one of these detected by screening may have their life “saved,” but this is offset by the number killed by the treatments and the large number who are left impotent and incontinent.

Here’s an evidence-based infographic from the Harding Center for Risk Literacy that explains the numbers – note that for every thousand men screened, up to 160 false positive tests will occur and up to 20 men will be treated unnecessarily (risking harm from unneeded surgery) with no clear mortality benefit.

 

Although Stiller dismisses those harms – incontinence, impotence, among others — as being “in the purview of the doctor treating the patient” (whatever that means), the fact is that the treatments themselves can be deadly or cause serious disabling side effects. Even the biopsy resulting from a false-positive PSA can lead to serious infections requiring hospitalization and – rarely – death.

In fact, the treatments can be so grueling that it’s possible they may increase other causes of death – canceling out any reduction in prostate cancer deaths. That’s why Prasad and others argue that overall mortality, and not prostate cancer mortality, should be the benchmark to assess benefits from cancer screening.

Celebrities have a responsibility to use their platform wisely

Another problem with saying the PSA saved his life: He might still die from prostate cancer, in spite of being tested. Sadly – and I very much hope this is not the case – it’s possible that Stiller’s cancer is one of the aggressive ones that will recur despite early detection and treatment – meaning that Stiller’s declaration of having his life “saved” will turn out to be premature. This is a reality that needs to be acknowledged. Everyone needs to choose their words carefully when addressing a topic as deadly serious as cancer.

That’s especially true for celebrities, who in our culture have an outsized platform to express their views. Timothy Caulfield, who studies celebrity health messaging at the University of Alberta, calls Stiller’s post “exactly the kind of celebrity advice that is not needed.”

The message that is conveyed by Stiller’s post is that PSA testing is a benign procedure (“it is a simple, painless blood test”) that only has upsides – that is, if you have the right doctor (how a patient is suppose to know this, isn’t clear). But his personal story is not evidence. This is a well-told anecdote, not good data that demonstrates that PSA testing is worthwhile. It is advice that can only confuse the public discourse surrounding PSA testing. More important, it runs counters to the emerging evidence-informed consensus that, for most, PSA screening is not helpful and may be harmful. But because the advice is coming from a celebrity, it will get pop culture traction and could encourage the utilization of a test that has questionable value.  And, alas, we also know that a powerful narrative, like the one in Stiller’s blog, can overwhelm even a mountain of good clinical data.  Bottom line: not helpful.”

How much traction is this getting? The Today Show, with its audience of millions, has already had Dr. Mehmet Oz on the show discussing the piece and its implications. It was great to see the sometimes evidence-challenged Dr. Oz pouring some cold water on Stiller’s claims and citing U.S. Preventive Services Task Force data on the very modest benefits — and considerable harms — of PSA screening.

Caulfield gives Stiller points for engaging the controversy around PSA testing and referring to the relevant policy statements. However, I’d note that Stiller’s thesis appears to reflect the views of his urologist, Dr. Edward Schaeffer, who’s helped promote fear-mongering messages about “skyrocketing” rates of prostate cancer due to reduced PSA testing. Those statements aren’t based on sound science as I pointed out in a post a few months ago.

Skewed statistics can certainly stir up fear that would lead to blog posts about the need for more PSA testing. But such posts telling personal stories are no substitute for a comprehensive assessment of the evidence. The choice that was right for Stiller is not right for everyone.

“Frankly, I am sick of celebrities telling anecdotes about cancer screening,” says Prasad.  “Screening is too important to too many people, and has too broad public health repercussions.”

Prasad adds: “When celebrities choose to volunteer some, but not all, of their health information they may affect health decisions for many Americans (as was seen with Angelina Jolie). As such, celebrities have a responsibility to do so wisely. I am afraid Ben Stiller’s post does not meet this mark.”

Note: Please see the comments section for additional commentary from Dr. Prasad that was edited from the post for length.

Comments (38)

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Kevin Lomangino

October 5, 2016 at 11:36 amThe following comment is from Vinay Prasad, MD, MPH, whom I interviewed via email for the main post above. I edited these comments from the post to improve readability, but I think the point is worth sharing.

Ben Stiller says “I was lucky enough to have a doctor who gave me what they call a “baseline” PSA test when I was about 46.” He notes this runs counter to the USPSTF and even the ACS. Ben Stiller says everyone over 40 should get a PSA, but why does he discriminate against 39 year olds? If you accept Ben Stiller’s logic, that we should do anything to find cancer early (with near total disregard for net effects, harms or overdiagnosis), why is 40 Ben Stiller’s cutoff? He criticizes the American Cancer Society for 50, and yet equally arbitrarily chooses 40. If Ben Stiller thinks a 40 year old should be offered a PSA, why not a 39 year old? Why not every man? Since Ben Stiller does not employ careful scientific reasoning to reach his position, I would argue that Ben Stiller is logically inconsistent.

If he believes we should do everything possible to prevent advanced prostate cancer (and that seems his position), the test should be offered to any man of any age. Also, if Ben Stiller was to push his own thinking, he would argue that a prophylactic prostatectomy should be offered to any informed man. After all, PSA screening misses some prostate cancer– he conceeds that. Why should a healthy person not be allowed to remove their prostate beforehand? Since prostate cancer accounts for 2-3% of all deaths, the number needed to treat would be 33-50, and not that dissimilar from the most optimistic estimates of the PSA from the European randomized trial. Actually, Ben Stiller–since he thinks cutting out cancer early is the main priority and does not seriously weigh harms and overdiagnosis– should support the prophylactic removal of all un-essential organs, as any may become cancerous.

The purpose of this thought experiment is to illustrate the absurdity with Ben Stiller’s position: a slight more aggressive, slightly less evidence based recommendation the ACS. He is surely entitled to his opinion, but unfortunately his celebrity status will give that opinion disproportionate influence.

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