Tuesday, November 2, 2010

Prostate Cancer and the United States Preventive Services Task Force

The WSJ reports that some family physician quit the United States Preventive Services Task Force over a disagreement regarding the upcoming proposed recommendation regarding PSA and Prostate Cancer testing of men.

The WSJ states:

As we also reported last week, last November the USPSTF voted at first to give prostate-cancer screening a “D” recommendation for all age groups, meaning the group recommends against screening for all age groups. Currently the USPSTF has an “I” rating for prostate-cancer screening, which means the current evidence is insufficient to assess the balance of benefits and harms, for men younger than 75. For older men, the rating is “D.”

Calonge told us that as report was being written, the group decided that the possible harms of screening also needed updating. So the USPSTF “voted to re-vote,” he said.

Also last November, the USPSTF published its updated recommendations for breast-cancer screening, which quickly got caught up in the political firestorm surrounding health-care-overhaul. The panel wasn’t prepared for the controversy created by its recommendation that women aged 40-49 who are at average risk of breast cancer should discuss the benefits and risks of screening with a physician rather than getting it as a matter of course.

Namely the panel seems to have been ready to issue a recommendation not to do any prostate cancer screening for any men at all! Have any of these people ever been to a cancer ward, spoken to a urologist in cancer practice. As we have stated before, the evidence is quite clear, PSA albeit a weak test, does save lives in certain segments. The problem is that we do not know what they are yet but why stop monitoring and go back to the dark ages of no data until death!

The problem is that we do not know what the genetic makeup is of the more aggressive prostate cancers. If we see a PIN is there also an aggressive ductal carcinoma present. How strong is the genetic linkage between first degree relatives of aggressive cancers and can this sub group be better treated and identified.

No, the good doctor, in my opinion, seems to have decided that he knows best and that one should throw out the baby with the bath water, or so it appears.

There is a report by the physician in question where he reiterates the NEJM and JAMA regarding the usefulness of PSA testing. Yet we had demonstrated when these reports came out that they had in our opinion significant flaws. We detailed our analysis herein. Prostate cancer is a complex genetic disease. It is not a single disease and indeed for the most part it is indolent. Yet there are those cases where it is highly aggressive, especially if there is a family history. The physician in question appears to ignore if not reject that fact.

This is the problem that we have been writing about here. We get some GS 11 or 12 who somehow gets to believe they are faultless and all knowing when the reality is that we do not know all but as a physician one has the duty of care to a patient, and then let the patient be part of the educated decision process. There are patients who now understand Goldstein's work on the Akt and AR activation which moves PIN to PCa. How do we deal with those patients if the typical family physician is seemingly clueless of the issue in toto?