Three urologists give their take on the frequency of patients presenting with prostate cancer.
Benjamin Lowentritt, MDLeading up to the [U.S. Preventive Services Task Force] screening recommendations, we were already seeing a shift-an increasing number of high-grade metastatic patients started showing up at diagnosis. It’s hard to separate what was happening before from what has happened since. Some primary care doctors had already stopped screening.
We don’t understand why some people have more aggressive cancers than others. I don’t think we can blame it all on decreased screening, but it can certainly be compounded by the changes in the screening recommendations.
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Attention should be paid to what we do with screening information. Treatment options today are very different than 20 years ago, options the task force based their recommendations on.
How does it make any sense to say, ‘We have a disease that’s potentially becoming deadlier-these are patients that can’t be cured, but we’re not going to try to find them at an earlier stage?’ You have to re-evaluate these recommendations in the context of the changing way we now react to the information screening yields. It should remind everyone that prostate cancer is a deadly disease for tens of thousands of men a year.
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If we wait until they come in with truly advanced cancer, we don’t have any chance of curing them. They can survive longer than they would have before-at a very high expense, by the way. So as we look toward any effort of value-based cost-effective care, it’s going to require us identifying it at an earlier stage. Living longer with metastatic disease should not be the goal of any efforts of how we manage prostate cancer. That would be very frightening. It points out the flaws in eliminating screening for a disease that has such an impact on so many lives.”
Benjamin Lowentritt, MD
We are, without a doubt, seeing a noticeable increase in the number of advanced prostate cancer patients.
This is all anecdotal, but within the last few years we’ve probably seen a grade shift with fewer Gleason 6 cancers and definitely more predominant 4+3, 4+4, and even 4+5 cancers.
One reason is the misinformation on PSA shared by primary care doctors. It’s gotten to the point where many PCPs don’t even discuss PSA screening with patients. Many don’t even do digital rectal exams.
The U.S. Preventive Services Task Force said potential complications-infection, anxiety associated with negative biopsy or multiple biopsies-were not outweighed by the lives saved by early detection. They took a very utilitarian approach making that choice. The task force validated what primary care and the American Cancer Society were pushing, many of us believed for financial incentives in the opposite direction.
The problem with discussing mortality is that even in people with advanced cancer, increased mortality won’t show up for 5-10 years. But more patients require more advanced treatment, such as chemotherapy, and pain medicine for bone metastases. Although they may survive several years, their quality of life goes down drastically.”
James E. Fagelson, MD
We haven’t actually been affected by the U.S. Preventive Services Task Force recommendation not to do PSA screening. I’m at Kaiser and we probably still adhere more to the AUA position. We really haven’t decreased the number of PSA screenings we do. We told our primary care physicians that it’s OK to continue doing PSAs up to a point.
As an HMO, we’re more resistant to what the government says we should do, unless we feel it’s useful. We’re certainly more judicious about our approach. A lot of people in observation don’t go to surgery. I’ve been following patients for years, and the vast majority do not progress. We never really did biopsy every elevated PSA. With electronic records, we can click back 10 years and see people’s labs, the patterns and trends.
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The issue is complicated by a number of things. First, advanced prostate cancers I see actually tend to be in older men who haven’t been tested for a number of years. We’re seeing a lot of people through the ACA, who didn’t have insurance before, who do now, and so they are being evaluated. That represents an influx of new people, so that muddies the water. Our department hasn’t seen a big increase because we really haven’t changed our practice pattern.
We know there are many reasons the PSA can be elevated. In my experience, prostate cancer is eminently treatable and curable. Unfortunately, most of the advanced cases we get are people who refuse biopsy. We have a large population of Hispanic men, and some absolutely do not want a biopsy. The PSA just keeps marching up, then there is trouble. Cultural issues are not easily overcome.”
Howard I. Winter, MD
Panorama City, CA
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