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Physicians Seeking Middle Ground in Prostate Screening Debate

 |  By jcantlupe@healthleadersmedia.com  
   November 03, 2011

For two decades, Michael Barry, MD, has struggled with the question of whether men should be screened for prostate cancer. Barry hoped the U.S. Preventive Services Task Force (USPSTF) would settle the long-running debate. But when the task force issued a draft recommendation last month against screening, Barry abandoned his hope for a definitive answer—primarily based on the use of one qualifying word: "small."

Barry, president of the Foundation for Informed Medical Decision Making calls the controversy over prostate-specific antigen (PSA)–based screening and treatment of screening-detected prostate cancer an argument that "refuses to die."

Although 20 million men undergo the screening each year, the task force insists that it isn't generally necessary. In October, the USPSTF set off the latest round of debate with this conclusion from its draft report: "Prostate-specific antigen–based screening results in small or no reduction in prostate cancer–specific mortality and is associated with harms related to subsequent evaluation and treatments, some of which may be unnecessary."

For men aged 50 to 69, "the evidence is convincing that the reduction of prostate cancer mortality 10 years after screening is small to none," according to the task force. "The evidence is convincing that for men aged 70 years and older, screening has no mortality benefit."

In making its findings, the task force last month referred to two several clinical trials, and noting that neither trial some showed no decrease in overall mortality with the use of PSA-based screening through 11 years of follow-up, and that all trials showed either a "small or no benefit" in prostate cancer–specific mortality, Barry wrote last month in the New England Journal of Medicine.

It's the word "small" that gets him, Barry says.

"Who is to decide what constitutes a 'small' benefit and whether it outweighs the potential harms?" Barry he asks.

"Weighing the pros and cons to make a decision about PSA screening is an individual process, and different well-informed men will make different decisions," Barry told HealthLeaders Media. Yet the task force's recommendation "removes the patient from the equation and puts the physician in the central position of discouraging use of the test."

"Uncertainty in medicine is more common than we usually let on, and the way to address uncertainty is to allow patients the central position in decision-making," Barry says.

The public has until November 8 to comment on the proposals. The USPSTF, an independent panel composed of primary care providers, conducts scientific evidence reviews of a broad range of clinical preventive healthcare services and develops recommendations for primary care clinicians and health systems.

Indeed, prostate cancer is a significant killer of men, and the issues surrounding the screening, which is designed to catch the cancer early, pose a dilemma for physicians and patients.

Prostate cancer is the most commonly diagnosed nonskin cancer in men in the U.S. In 2010, an estimated 217,730 American men received a prostate cancer diagnosis, and an estimated 32,050 men died from the disease. The majority of deaths due to prostate cancer occur after age 75.

One of the problems with the PSA test is that it often produces false-positive results that are associated with negative psychological impacts, including a patient's persistent worry about prostate cancer, according to the task force. Men who have false-positive tests are more likely to seek or have additional tests, such as biopsies, that also trigger a host of other ailments, the task force states. "The evidence is also convincing that PSA-based screening leads to substantial overdiagnosis of prostate tumors," the report adds.

The task force's latest findings will replace a 2008 report that showed insufficient evidence to make a recommendation about PSA-based screening for men under 75. At that time, the task force recommended against screening for men 75 and older.

But Barry believes the USPSTF recommendation is too black-and-white. "What I'm espousing is the middle of the road," Barry says. "I absolutely agree that many men look at that [the report] and say that's a really small benefit for the harm of potentially doubling my risk of getting prostate cancer and all the side effects of treatment that may come with it, but I think other men would look at the same data and say, 'For me, it's worth it.' So rather than solving it with a one-size-fits-all recommendation for everyone, I like doing it on the individual level."

Many other physicians have mixed reactions to the recommendations. In a survey of "Top Doctors" conducted by U.S. News and World Report, more than 60% of internal medicine specialists said they would continue testing despite the task force recommendation.

Barry acknowledges that many physicians have a "dubious" record of decision-making for PSA testing. "We have been ordering PSA tests without discussion. We have been ordering them in very old men without anything to gain," he says.

For primary care physicians, however, serious conversations about the issue have been compromised during regular office visits, wrote Allan S. Brett, MD, and Richard J. Ablin, PhD, also in last month's New England Journal of Medicine.

"The idea that physicians could initiate truly informed discussion was wishful thinking," Brett and Ablin write, "because clinicians and patients had to consider an enormous list of probability estimates and uncertainties."

"Patients were not really making informed decisions and office-based discussion of the pros and cons of PSA testing was essentially a charade," they add.

While the controversy continues over PSA testing, that charade must cease, as Barry sees it. Physicians must take the time—or at least provide patients the proper educational tools—to help men make an informed choice about PSA screening.

Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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