Radiation oncologists against new USPSTF prostate cancer guideline

The United States Preventative Services Task Force issued a new guideline in May recommending against PSA screening for prostate cancer altogether.  This government based panel has been getting the deserved pushback from the American Medical Association (AMA) as well as from the American Urological Association (AUA).  


Here's a prior blog post with my thoughts on this as well as the AUA response with current PSA screening guidelines from the AUA as well the American Cancer Society.


I wanted to share in this post a statement from the American Society for Radiation Oncology (ASTRO).  These doctors are on the front lines with us (urologists) in fighting prostate cancer.  ASTRO also has lined up against the new USPSTF guidelines.  

ASTRO statement

My analysis:


I agree with Dr. Gunderson's quote on this issue.  There certainly is an over diagnosis issue with prostate cancer.  However, as active surveillance is becoming a viable method to keep track of the disease, advocating for a wholesale cessation of PSA based screening is like throwing out the baby with the bathwater.


Dr. Sandler also makes a great point in the release. The prostate cancer screening issue is not a problem that a cookie cutter approach can solve.  With multiple factors such as age, expected longevity, race, symptoms, and family history, each situation is unique and each man should have the opportunity to make an individual informed decision on the matter with his physician.

AMA tells USPSTF to incorporate specialists in guideline creation

Resolutions were passed at the American Medical Association House of Delegates Meeting admonishing the USPSTF regarding their screening guidelines on mammography and PSA screening.


Here are the passed resolutions: (Source: AUA e-mail alert)

RESOLVED, That our AMA expresses concern regarding recent recommendations by the USPSTF on screening mammography and PSA screening and the effects these USPSTF recommendations have on limiting access to preventive care for Americans.

RESOLVED, That our AMA encourage the USPSTF to implement procedures that allow for meaningful input on recommendation development from specialists and stakeholders in the topic area under study.

Here is coverage from ABC News on the topic. 


The recent USPSTF guidelines for PSA screening were done without the input from the American Urological Association.  This is a big tripping point for me on the guidelines since we urologists are the main doctors who take care of men with prostate cancer.


Further, the USPSTF membership lacks oncologists and urologists. Here are the current members of the USPSTF: 


I applaud the AMA for taking a stand on this. Specialists represent a great resource for the crafting of these guidelines and need to be involved at the ground level, not after the fact.  Not involving main stakeholders who implement such guidelines reduces buy-in from the medical community as well as patients.

Zytiga (abiraterone) for advanced prostate cancer before chemotherapy - ASCO 2012

Testosterone is a major fuel for prostate cancer growth.  Despite use of agents to induce clinical castration, men can continue to have advancing disease.  Zytiga (abiraterone) is pill that directly suppresses the synthesis of testosterone at multiple points in the body to further decrease testosterone production.   It is currently FDA approved for advanced castrate resistant prostate cancer after use of Taxotere (docetaxel) chemotherapy.  This indication restricts to use of this agent to the most advanced cases.


At this year's American Society of Clinical Oncology (ASCO) meeting, there was an exciting abstract about treating men suffering from advanced castrate resistant prostate cancer with Zytiga (abiraterone) before using chemotherapy.  Abiraterone caused improvement in progression free survival, time to narcotic use, time to use of chemotherapy, time to deterioration in clinical performance status, and time to PSA progression.  The study was terminated early due to the degree of improvement at interim analysis.


Here are links to media coverage of this abstract:
Reuters for a general audience.
Medpage Today coverage - more technically inclined.


This will likely lead to an expanded FDA indication in the future for use prior to chemotherapy.  Men will then have earlier access to this oral agent to combat the disease.

My take on USPSTF final prostate cancer screening guidelines

The US Preventive Services Task Force (USPSTF) released its final prostate cancer screening guidelines on May 21st, 2012, during the American Urological Association Annual Meeting (curious timing...in my opinion).


The task force recommended against PSA-based screening altogether for prostate cancer by giving the practice a "D" rating.  From the USPSTF grade definitions site this means: "The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits."  The task force suggests that healthcare providers: "Discourage the use of this service." This recommendation is no different than the draft recommendations issued in October, 2012 despite vocal opposition from many sources.


The American Urological Association (AUA), American Cancer Society (ACS), and National Comprehensive Cancer Network (NCCN) have issued guidelines recommending men to have discussions with their healthcare providers regarding the risks and benefits of prostate cancer screening.


AUA Guideline
ACS Guideline
NCCN Guideline


The AUA has expressed its vigorous opposition to the the final USPSTF recommendation.  AUA President, Dr. Sushil Lacy, released this statement about it on behalf of its members.  The AUA also has a website about the issue and prepared a fact sheet about PSA testing for its members.


My take:
The PSA screening controversy is a complex issue.  There are many factors involved in screening such as age, expected longevity, race, family history, and urologic symptoms.  I believe that at this time, the USPSTF blanket recommendation is too simplistic.  I urge men to talk further with their healthcare providers regarding this issue and consider referral to a urologist if there are still lingering questions about prostate cancer screening.  Also, the diagnosis of prostate cancer does not necessarily mandate treatment.  Depending on the clinical scenario, monitoring of the disease or "active surveillance" can be a viable option for many men.

Useful prostate cancer video from NH Prostate Cancer Coalition

A very informative video from the New Hampshire Prostate Cancer Coalition (NHPCC) about prostate cancer and prostate cancer screening was just uploaded to their website.  It features Dr. William Santis, my partner, who is Director of Prostate and Urologic Cancer at Concord Hospital.


He honestly explains in layman's terms prostate cancer screening as well as the screening controversy.  The video has a nice diagram of the lower male urinary tract as well as useful facts about prostate cancer.


Please check out the video and post any feedback so I can relay this the NHPCC and Dr. Santis.

Warren Buffett and President Obama vs. USPSTF guidelines

As an 81 year old man, it's ironic that Mr. Buffett is in the demographic that the United States Preventive Services Task Force (USPSTF) recommends against screening.  The current official recommendation from this body is that people aged 75 years of age or older should not be screened.

USPSTF prostate cancer screening guideline - 2008 (in revision)

This guideline is old and their current draft guidelines advise against screening altogether.  This new proposed guideline was released in October, 2011 and had two comment periods after release.  Their final recommendation is pending.

USPSTF draft guideline against all screening for prostate cancer

The new proposed guideline has drawn the ire of many groups, with the American Urological Association leading the way.

AUA page with USPSTF response

I too have been involved in the response, sending an editorial to the Concord Monitor.  In particular, I detail the interesting fact that while this controversy is going on that President Obama just had a PSA test. If the new draft guidelines were used, he would be advised against having the test.  I feel that he should have the test and continue to do so, especially since he's in an at-risk demographic by being African-American.

As stated in my prior blog post about Warren Buffett's cancer, I think using age alone is a very simplistic cutoff.  Prostate cancer is quite complex and the medical data is still evolving.  There is little controversy that there is a problem with the over diagnosis of prostate cancer.  However, diagnosis does not necessarily mean treatment.  One good aspect of this controversy is that there is more awareness that many men have very low risk disease and can be managed with active surveillance.

The bottom line is that we currently don't know which patients with prostate cancer will die of that disease.  Until this issue is further clarified with more clinical studies or a breakthrough in prostate cancer detection, men should have an informed discussions with their doctors regarding this issue on a case by case basis.  It is premature for the USPSTF to issue such a blanket statement that affects the health of millions of men in the United States.

Warren Buffett's prostate cancer disclosure and treatment

Since Warren Buffett's recent disclosure of prostate cancer has made a lot of headlines, I thought I'd share some commentary on it today.

Mr. Buffett's letter to shareholders revealing that he has prostate cancer.

My thoughts as an outside observer:

It seems that he has T1c or prostate cancer detected by PSA testing alone.  Since we don't know his PSA history, Gleason score (a number that tells us how aggressive the prostate cancer cells are), or number of cores positive in his biopsy, it's difficult to know exactly how much disease he has in the gland or how risky it is.  Warren Buffett's treatment with 2 months of external beam radiation therapy is a mainstream option for someone electing to be treated for this disease.

It is controversial in the medical community as to whether nor not a man of his age (81 years) should have been screened in the first place.  Since Mr. Buffett seems to be a man in excellent health with a likely expected longevity of 5-10 years, such screening may have been reasonable.  In my opinion, a chronologic cut off for who should and shouldn't be screened seems overly simplistic.  There are many factors aside from age such as anticipated longevity, family history, and race that also need to be taken into account.  Therefore, I encourage men to have an individualized discussion with their doctors regarding the risks and benefits of prostate cancer screening. 

Mr. Buffett's prognosis is excellent.  Since we don't have his cancer specifics, we can rely on general prostate cancer survivorship data.  From the American Cancer Society, his 5 year relative survival rate is nearly 100%, his 10 year relative survival rate is 98%, and his 15 year relative survival rate is 91%.  Plenty of time for him to work out a succession plan for Berkshire Hathaway.

American Cancer Society survivorship page for prostate cancer

Best of luck to Warren Buffet and his family as he embarks on his treatment.

How is the Prostate Examined?

The prostate is felt or "palpated" via digital rectal exam or "DRE". 

See figure below:

Source: Wikimedia Commons and NCI

In this cutaway side view, the doctor's finger is in the rectum and digitally examining the prostate gland.

When your doctor does a DRE he or she is assessing several attributes regarding your prostate:

• Size - How big is the gland?
• Symmetry - Is one side or "lobe" different in size compared to the other one?
• Contour - Are there any lumps or "nodules" within the gland?
• Consistency - Are there any firm areas within the prostate?

A well trained clinician can detect all these factors pretty quickly from the exam.  If an abnormality is found the patient may be offered a prostate biopsy to determine whether or not the prostate harbors cancer.

As a urologist, I believe that when a patient elects to be screened for prostate cancer a digital rectal exam should be part of the process.  Though screening for prostate cancer is a controversial issue, much of the attention has been around PSA testing alone with little acknowledgement of the utility of the DRE.

The DRE is also helpful in assessing the prostate for other conditions such as benign enlargement of the gland or "BPH" or prostatitis.