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"We’re definitely seeing fewer men referred for elevated PSAs," one urologist told Urology Times.
"I would say I’m seeing a slight decrease in the number of men having the PSA done, especially among older guys-those in their 70s and 80s. But I think men in their 50s and 60s who need to get checked are getting checked. Some of that has to do with primary care physicians and the way they practice. Some are checking PSAs less often. So it’s a little different but not a whole lot.
If I saw a trend where guys in their 50s or 60s were coming in with elevated PSAs and hadn’t been checked for a while, that would start to concern me. I haven’t seen that yet, but it’s still early. I don’t know to what degree, but that certainly may happen.
I look at older men on more of an individualized basis, based on their overall health status. After we discuss things, I let them make their own decision. I’m glad to check it if they want. I think the primary care doctors are checking them less often, so now we’re pretty much just waiting to see what happens.”
Todd Johnson, MD
Overland Park, KS
Next: "We continue to be advocates of screening followed by more nuanced actions based on the PSA."
Dr. Hennessy"There’s some decrease in screening by primary care physicians, but having said that, I can’t say more of the patients we see with elevated PSAs result in an increase in our positive biopsy rate. I haven’t seen a stage migration yet resulting from the screening delays. We continue to be advocates of screening followed by more nuanced actions based on the PSA.
We may not biopsy a person at the first sign of an elevated PSA. But we certainly recommend that when a PSA is rising too rapidly, or is just too high for their age, patients be biopsied. We’re a pretty localized community in a one-hospital town. In the 30 years we’ve been here, we’ve pretty well educated our primary care physicians and brought them along with the philosophy of PSA screening.
There certainly is a group of primary care physicians that has gotten on the no-screening bandwagon, but that’s not predominating, so I’m not getting a sense that a lot fewer men are being tested.
We’ve always been proactive in getting information out to our patients. We sent an email to our patients that we do believe in screening, and we’ve tightened our indications for biopsy because you can’t ignore a disease that still kills tens of thousands of men a year.
There’s a lot of Gleason 6 PSAs that can be monitored without treatment and people who present with 7s and above who, despite treatment, seem to progress. So where do we really impact the disease? In every other tumor model, there’s a point in time when the tumor was confined to its organ of origin. We’re trying to determine which prostate tumors have the potential to spread and metastasize. We want to identify those cancers that pose a threat early enough, so we can impact survival.
But tell you what: Talk to me in about 5 years. With prostate cancer, that’s the minimum time we’re talking about to determine the effect of our actions.”
William T. Hennessy, MD
Next: "We're definitely seeing fewer men referred for elevated PSAs."
Dr. Long"We're definitely seeing fewer men referred for elevated PSAs. The number of biopsies we’re doing is also down as a result.
Men who do come in are more likely to come in with higher PSAs and we find when we do biopsies, we are more likely to find more advanced prostate cancer as well.
This is definitely concerning. There is a lot of controversy over PSA testing, but to just throw out everything and go back to the pre-PSA era is not the right thing to do. Rather than giving up on it, we have to be smarter about who we’re screening and when we do biopsies. We’ve got extra tools now that make it a little more accurate and help us risk stratify patients better.
For a lot of primary care physicians, it’s a really bewildering issue, and for good reason. Nobody can really give you a straight answer about what we should do and when we should do it.
Because the family practice organization recommended against PSA screening even before the task force came out against it, family practice physicians seem a little more confident in their decision not to do PSA screening, as opposed to other primary care docs who are a bit more confused and want to make sure they are doing the right thing.
I practiced in a smaller community in Maine for 15 years before coming to California. Some primary cares there were responsive; others were incredibly vocal. They would basically imply that I was just case hunting, looking for money. In California, it seems primary care docs are a little more likely to screen.”
Richard Long, MD
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