Urologists have long recognized the wide differences of prostate cancer biology. These differences are largely responsible for the variability in outcome.
Patients with aggressive cancers usually progress and are likely to need treatment. However, patients with low-grade prostate cancers may not progress and may not need treatment. In these cancers, a significant number of men receive treatment for a cancer that probably doesn't need to be treated.
In response, the recent United States Preventative Services Task Force report has determined that the use of routine PSA (Prostate Specific Antigen blood test) testing is unnecessary. This dangerous report may lead to future denials of the use of PSA testing in men, which will be a substantial impediment in providing high-quality care.
In contrast to this report, urologists have already taken steps to improve detection of prostate cancer at its earlier stages and identify men who may not need treatment.
Prior to PSA, cancers were detected by physical findings or lower urinary tract symptoms. Unfortunately for many, this is too late for cure. PSA is the most sensitive indicator to detect prostate cancer. PSA screening has resulted in a decrease in advanced prostate cancer at presentation and allowed more men to undergo potentially curative procedures for earlier stage disease.
Thus, widespread screening programs to detect men with smaller, localized prostate cancer followed. More cancers were detected in earlier stages and resulted in more procedures for treatment. With more men undergoing treatment, complications did increase. In addition, the concerns of treating men with potentially insignificant low-grade cancers were recognized.
Urologists have already addressed these very important issues by changing methods in the diagnosis and management of prostate cancer. The American Urological Association has published Clinical Guidelines that specifically recommend limiting the use of PSA screening to at-risk populations and educating all men regarding the risks and benefits of PSA screening (including overtreatment).
Thus, we are currently recommending selective use of PSA screening. Additionally, urologists are increasingly using active surveillance as a viable treatment strategy for low-risk localized prostate cancer. This consists of closely following serum PSA blood tests and repeating biopsies, reserving aggressive therapies such as surgery or radiation for patients who truly need it.
These are contemporary best practices of prostate cancer, which is not the focus of the task force report. The report focuses on PSA screening. As clinicians, our focus is on outcomes. We use PSA as an integral part in the diagnosis and management of prostate cancer. This is not reflected in the task force report and is the major deficiency in the recommendations.
In an era where we can actually localize cancers and apply targeted therapies to treat prostate cancer, we continue the quest of decreasing complications from the treatment of prostate cancer. To abandon the use of PSA testing is relegating us back to the 1960s and digital rectal examinations. By then, it's just too late.
Here lies the powerful issue of patient choice. Can we really tell a 62-year-old man not to worry at all about his low-grade prostate cancer and that treatment is unnecessary? No, we cannot. The truth is, we can try to predict his outcome but not with absolute certainty.
In 2011, I should be able to choose a PSA test if I want and make an informed decision with my doctor to treat my cancer. That's not unnecessary treatment. It's patient-focused care, and that should be the standard. Breast cancer advocates clearly acknowledge that early detection and treatment choice is much better than silent, incurable progression. Again, the task force report misses this point.
I hope many men are as concerned about a report based on technology and treatments as old and outdated as the diagnostic methods we may be relegated to. Gentlemen, we should follow the lead of women who rallied with outrage when the task force made similar reckless recommendations about screening mammography.
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Dr. J. Christian Winters is professor and chair of Urology at LSU Health Sciences Center New Orleans School of Medicine.
Source: http://www.nola.com/opinions/index.ssf/2011/11/early_detection_vital_in_prost.html
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