Raoul S. Concepcion, MD
Editor-in-Chief, Urologists in Cancer Care
Director of Clinical Research,
Urology Associates, PC
Mark S. Austenfeld, MD
Kansas City Urology Care
Saint Luke’s Hospital
Kansas City, Missouri
E. David Crawford, MD
Head, Urologic Oncology
University of Colorado
Neal D. Shore, MD
Director, Carolina Urologic
Grand Strand Urology/Atlantic
Myrtle Beach, South Carolina
Paul R. Sieber, MD
Urological Associates of Lancaster
In May 2012, the US Preventive Services Task Force (USPSTF) recommended against PSA screening for prostate cancer in men regardless of age, citing evidence of a very small potential benefit from screening and significant potential harms.
In the aftermath of this recommendation, a number of medical organizations issued formal statements of disagreement, including the American Urological Association (AUA), which stated in part that “…the PSA test provides important information in the diagnosis, pretreatment staging or risk assessment and monitoring of prostate cancer patients….”
Editor-in-Chief of Urologists in Cancer Care, Raoul S. Conception, MD, Director of Clinical Research at Urology Associates, PC, in Nashville, Tennessee, moderated a panel discussion with physicians (see sidebar for the full list of panelists) as part of a video series from the Urologists in Cancer Care Peer Exchange program
As part of a more extensive discussion about clinical and practice management issues that urologists face, Concepcion asked panel members for their thoughts on the USPSTF recommendations, and how this widely publicized health message has impacted their urology practices.Concepcion
: Let’s talk about prostate cancer screening. We know that the United States Preventive Services Task Force came out recently with a very controversial recommendation regarding PSA screening for prostate cancer. Dr Crawford, let’s start with you.Crawford
: My short answer is that there is a lot of truth in what they say. In 1989, we started one of the biggest organized national prostate cancer screening events, Prostate Cancer Awareness Week, which has been in place ever since. Millions of men have been screened, and we have learned a lot. Where we got into trouble was by diagnosing people who maybe did not need to be diagnosed and treated. The bottom line is that we need to separate diagnosis from treatment. Not everyone who is diagnosed needs to be treated.
If you don’t believe in overdiagnosis and overtreatment…I can say that I see it all the time. Patients come in with a PSA of 45 and Gleason score of 6 in one core, and they get a robotic prostatectomy or IMRT [intensity-modulated radiation therapy]. Does this person really need to be treated?
I am not sure that we should be attacking the USPSTF. We should find some common ground and work on better ways to identify who needs to be screened.Concepcion
: Dr Austenfeld, like most of us, you wear multiple hats. Could you comment with your American Association of Clinical Urologists (AACU) hat as well as your clinician’s hat as a key part of a large urology group?Austenfeld
: I think most of urologists in this country feel that the USPSTF overstepped its bounds and didn’t listen to some of the expert opinion and advisory groups, particularly the AUA and experts who were able to break down some of the studies. They only used two studies primarily, and the follow-up was short.
And, as we know, there were neither oncologists nor urologists on the panel. It is true that they may have some biases, but there are a great number of researchers in urology in this country who can give a good and unbiased professional opinion about this. Also, the Task Force had a chance to go back and revise its recommendation and didn’t. I think most people feel they plowed ahead without really good data, or at least [interpreted] the data incorrectly.
I agree with David that we probably diagnose too many men with prostate cancer, and some are overtreated. But we can’t ignore the fact that the death rate from prostate cancer has declined from the early days of PSA screening. We also can’t deny the fact that many men who suffer from prostate cancer live for many years before they die from the disease. So, death from prostate cancer as an endpoint is probably not very good.