Prostate cancer screening: It’s time for advocates to put up or shut up


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15 comments

  1. Mike Fraumeni

    Excellent read! Alerts men to what may be going on behind the scenes with this issue. Clearly as you say, harms that may happen with false-positives is an issue that does need to be specifically and clearly accounted for. First do no harm as the saying goes. This reminds me of something close to my personal situation now, a diagnosis of “conversion disorder” and as this peer-reviewed article mentions, harms can happen from such a diagnosis as this — “Such interference is an important problem, if the diagnosis is accurate. But, in the (more likely) event that it is not accurate, this defensiveness can interfere with both important mental health care and further ongoing necessary medical care.” In: “Problems with diagnosing Conversion Disorder in response to variable and unusual symptoms” – Barnum R. Adolesc Health Med Ther. 2014 Apr 17;5:67-71. doi: 10.2147/AHMT.S57486. eCollection 2014. PubMed PMID: 24808723; PubMed Central PMCID: PMC4000178 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4000178/

  2. Murray Krahn

    i) PSA screening remains a difficult issue, a controversy that has survived the publication of the big trials we thought would put this issue to bed.
    ii) Many guideline groups though, including arguably the CTF, though, don’t give due weight to mens’ preferences. It is about the frequency of events conditional on screening. But it’s also about the meaning of those events, the value or weight that men, and their loved ones, ascribe to labelling, reassurance, PSA anxiety, impotence, incontinence etc. Most guidelines make some effort to count things. Few make a serious effort to review the literature on mens’ values, preferences, experiences for those things. I think it’s really important for guideline developers to treat the evidence in this domain as evidence, and make a good faith effort to find and synthesize these data
    iii) There are a lot of modeling efforts too, which are typically not included in clinical practice guidelines. Many show that there is likely to be a small to very small mortality benefit that must be set against the potential positive and negative health related quality of life events associated with screening. If one is to be serious about the counting thing, I would urge the CTF to start using the best methods of counting- decision- and health economic modeling.

    http://www.cmaj.ca/content/early/2014/10/27/cmaj.141252

    • James Dickinson

      Dear Murray, Thank you for your comments.

      You are right that ultimately the preferences of men are most important in deciding what to do. But preferences based on biased or incomplete knowledge are built on quicksand: they are like the poor republican voters who oppose Obamacare because it is a socialist plot. So synthesising data on preferences based on what men have been told by the prostate screening advocates is useless.

      Too many opinions are based on the “survivors” who have done well. They were diagnosed and treated, and now have no sign of cancer. So they believe they were saved by the treatment – neglecting that most of them were overdiagnosed and would have done well regardless. To be “cured” of a disease that would not kill until the age of 120 is not a great victory. We hear little from those whose lives have been made a misery by the process. Yet their stories matter too. Even more those who have been treated, were caused harms immediately, but still die of the disease in the end.

      Only when we can tell men honestly what the “conditional probabilities” really are, can we have valid preferences. And the modelling you describe merely erects an even shakier superstructure on those wobbly foundations.

      It has been argued that the Canadian Task Force used old and out of date evidence, but perforce it had to use what is available at the time. The urologists and advocates who say “things are better now”, could analyse the latest data from Canadian sources that they control and can perhaps provide better information to assist men to choose. Until they do, men must either follow the Task Force or other decision aids, or choose based on hopes and beliefs rather than facts: a poor basis for decisions.

      • Mike Fraumeni

        Hopes and beliefs are important as well though as they make us who we are in large part and not simply facts regardless of how “evidence based” they are. Decision making is a multi-factorial process.

  3. Elizabeth Rankin

    This is a good article. If surgeons were honest about this topic they wouldn’t make the money they make doing surgery. Equally significant, the medical students they “teach” and those specializing in urology “wouldn’t get the experience” they need to prepare them for the work they anticipate doing if they had fewer patients designated for all the “testing” and surgical procedures” patients endure.

  4. Ed Weiss

    This is very timely. As a family doctor, the controversy around PSA screening is definitely something I come across very frequently. Just the other day I had a very heartfelt conversation with a patient who had a PSA-detected prostate cancer and was agonizing over whether to go ahead with surgical treatment or not.

    One thing that I think would really help, regardless of what one thinks about PSA testing, is a more straightforward way to discuss possible outcomes with patients. I like the “Best case/worst case” strategy and I think it’s very applicable here — more info at https://www.youtube.com/watch?v=FnS3K44sbu0

    • Andreas Laupacis

      Hi Ed. Thanks for the youtube link. Really excellent. i am embarrassed to say I haven’t seen this before. Really, really useful.

  5. ROBERT ROYCE

    Excellent article. Well argued. It seems to me that an evidence based approach to screening comes a poor second to a public health approach based on ’emotional appeal’, and that questioning the health economics and efficacy of such screening is seen as bordering on the socially unacceptable. This is one reason why politicians (at least in the UK where I live) are reluctant to get into that debate.

  6. Norma Bateman

    Thank you for your enlightening comments. Rarely are we privy to information questioning these practices. I am presently undergoing breast cancer treatment and am relieved that I do not need to be questioning these issues.

  7. Pam Heard

    The PSA test remains our most important tool in diagnosing prostate cancer, and we support screening men who are properly informed. Through individualized and shared decision-making, we have lessened the chance of unnecessary treatment. We are proud to set the standard for supportive care before and after treatment, and we are also leveraging PSA screening to empower men to be more active in their health care.
    While some prostate cancers grow rapidly and metastasize or spread, others grow very slowly and are unlikely to metastasize. This low risk prostate cancer may not need to be treated as soon as they are diagnosed. Slow growing prostate cancer may not have time to cause significant problems and the complications and side effects of treatment may outweigh the advantages. In Calgary’s Prostate Cancer Centre’s active surveillance clinic, men are carefully monitored. Treatment can be given if the cancer is progressing or if the patient decides on further treatment. Over treatment of men with low grade cancer is not an issue in Calgary.
    We would welcome anyone to come to Calgary’s Prostate Cancer Centre and talk to any one of our Urologists, staff, or patients working in the field of prostate cancer to see the world-class clinical work that is being provided to our patients and their families.

    Kevin V Carlson MD FRCSC DABU
    Clinical Associate Professor and Section Head of Urology
    Department of Surgery Cumming School of Medicine
    University of Calgary

    Eric Hyndman, MD, PhD
    Urologist, Clinical Assistant Professor University of Calgary, Southern Alberta Institute of Urology

    Bryan Donnelly, MD, MSc, FRCSC
    Urologist, Clinical Associate Professor University of Calgary, Co-Founder of Calgary’s Prostate Cancer Centre
    Dr. Geoffrey Gotto, MD, MPH, FRCSC
    Department of Surgery, The University of Calgary
    Southern Alberta Institute of Urology

    • James Dickinson

      Dear Ms. Heard, and Drs. Donnelly, Carlson, Hyndman, Donnelly and Gotto,

      Thank you for your response. My article was aimed to challenge the policies of the national organisations, not at activities in Calgary specifically. However, I will happily take you up on this invitation. When I visit, I would really like to learn how you properly inform men before they choose screening, and the way that you undertake “informed decision-making”. I would love to see your data that demonstrates the quality of your care, and how much you reduce overdiagnosis and overtreatment. Even better if you can publically describe it so all may know how good your centre is.

      • Pam Heard

        Thanks so much for your response. We are actually trying to set up a symposium in September to address the issue of informed PSA testing, harm from needless biopsies, and our Active Survellience Program (we are a world site) . We think it would be a great idea to have you and anyone else you wish to have on the panel, along with a few of our Calgary urologists to discuss these issues. There would be a full media scrum and Raj (CBC doctor) has agreed to host. Please feel free to contact me by email with some possible dates.
        Regards
        Pam

        • James Dickinson

          Dear Ms. Heard,

          This symposium sounds interesting. However, for the national audience, perhaps you can share links to your evidence and materials so that all can think about your assessment of the benefits and risks, as requested in my opinion piece above. After all this is a complex set of issues, and such matters are best worked through with slow thought and reflection, not the cut and thrust of verbal debate, nor the “sound bites” of a media scrum.

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