Tuesday, May 22, 2012

Prostate Cancer Screening, The Task Force

The USPSTF has issued its dictum on PCa screening with PSA. It states:

The USPSTF recommends against PSA-based screening for prostate cancer (grade D recommendation). 
This recommendation applies to men in the general U.S. population, regardless of age. This recommendation does not include the use of the PSA test for surveillance after diagnosis or treatment of prostate cancer; the use of the PSA test for this indication is outside the scope of the USPSTF. 

 It continues:

Men with screen-detected cancer can potentially fall into 1 of 3 categories: those whose cancer will result in death despite early diagnosis and treatment, those who will have good outcomes in the absence of screening, and those for whom early diagnosis and treatment improves survival. Only randomized trials of screening allow an accurate estimate of the number of men who fall into the latter category. There is convincing evidence that the number of men who avoid dying of prostate cancer because of screening after 10 to 14 years is, at best, very small. Two major trials of PSA screening were considered by the USPSTF: the U.S. PLCO (Prostate, Lung, Colorectal, and Ovarian) Cancer Screening Trial and the ERSPC (European Randomized Study of Screening for Prostate Cancer). 

The U.S. trial did not demonstrate any prostate cancer mortality reduction. The European trial found a reduction in prostate cancer deaths of approximately 1 death per 1000 men screened in a subgroup of men aged 55 to 69 years. This result was heavily influenced by the results of 2 countries; 5 of the 7 countries reporting results did not find a statistically significant reduction. All-cause mortality in the European trial was nearly identical in the screened and nonscreened groups. 

 The dissenting view stated:

Prostate cancer death was reduced by 21% in the screened compared with the control group and 29% after adjustment for noncompliance (5). The Task Force concluded that this decrease in prostate cancer–specific mortality amounted to few lives saved and did not outweigh … 

The recommendations of the USPSTF carry considerable weight with Medicare and other third-party insurers and could affect the health and lives of men at high risk for life-threatening disease. We believe that elimination of reimbursement for PSA testing would take us back to an era when prostate cancer was often discovered at advanced and incurable stages. At this point, we suggest that physicians review the evidence, follow the continuing dialogue closely, and individualize prostate cancer screening decisions on the basis of informed patient preferences.  

Now for our comments (see our draft book on PCa) :

1. We have discussed fatal flaws in our opinion in both studies relied upon. Simply they both used the old PSA threshold of 4 and did not include age dependency, percent free PSA and PSA velocity. In addition the European study had too great a time interval between tests.

2. No single PCa is alike. As we have been demonstrating for the past four years, the genetic makeup of PCa is complex and there are clearly certain specific markers for highly malignant PCa. By abandoning the test is throwing the baby out with the bathwater.

3. In my opinion this is a clearly age biased result, with the intent of removing care from the second highest cause of death amongst men. One wonders why!

4. Genetic makeup and family history are major drivers. PSA irregularities are one, along with PC3A testing, to ascertain PCa potential. Why eliminate it. The reason seems to be the cost of subsequent procedures, yet the Task Force argues it is the morbidity to the patient. Frankly morbidity in a competently performed procedure is less than a tooth extraction. Perhaps excess morbidity is more in the mind of the Task Force than reality.

What then is lost? We believe a great deal.

1. We are just beginning to understand the genetic makeup, just look at some of our recent postings, so that having the pool of data is indispensable. Having a genetic profile of multiple PCa would be the key to understanding the dynamics of PCa and its control.

2. What is the value of one life. If one has seen the agony of bone mets in a PCa patient, the results of DIC, and the loss of any dignity in the final days with catheter changes by a less than friendly "health care worker", the morbidity issue pales in comparison.

Hopefully we can find ways to work around this less than useful Government cost cutting "death panel" regulation. Welcome to our new world of health care!