Medical: The ABCs and Ds of Whether to Get Prostate Cancer Screening – NYT

The ABCs and Ds of Whether to Get Prostate Cancer Screening

Aaron E. Carroll – The New Health Care | The New York Times

It can be hard for physicians to follow current thinking of experts on medical care. It must be exponentially harder for the public to make sense of it. Recently, the United States Preventive Services Task Force changed its recommendation on prostate cancer screening from a D (that is, don’t do it) to a C (discuss it with your doctor).

Although there seemed to be a lot of coverage of this announcement in the news media, and a fair amount of excitement, there are two things men should know. First, it’s a good thing that recommendations change over time; second, this change isn’t as big a deal as you might think.  

The task force is made up of volunteers who are experts in primary care and preventive medicine. They are charged with evaluating the benefits and harms of preventive services (like prostate cancer screenings) to determine whether they should be widely performed. An “A” recommendation from the panel can be interpreted as an endorsement that everyone get a service because there’s a high certainty of a substantial benefit. A “B” recommendation is similar, but means that there’s only a high certainty of a moderate net benefit.

A “D” recommendation advises patients not to get a service because there’s a moderate certainty of no net benefits, or because the harms from a service outweigh the benefits.

Five years ago, the task force gave prostate cancer screening a D recommendation because there are real harms from over-diagnosis of the disease. Over-diagnosis leads to unnecessary treatments, and a newly discovered cancer could lead to no symptoms or harm over the patient’s lifetime. The treatments for prostate cancer, including radiation and prostatectomy, have high levels of adverse events. About 75 percent of all the men treated will have impotence, incontinence or both.

Further, at the time of the 2012 statement, there appeared to be little evidence that screening with a prostate-specific antigen blood test (PSA) reduced prostate cancer mortality. With no clear benefit, and significant harms, a D recommendation seemed appropriate.

Many disagreed. They argued that there were benefits to screening, and that those would be shown through better research. They were, to some extent, correct.

In 2014, researchers for the largest randomized controlled trial to date published an update of an earlier study, and it showed that offering men screening reduced their relative risk of dying of prostate cancer over 13 years by 21 percent. Another study published in late 2012 showed that offering screening reduced the relative risk of metastatic disease by 30 percent.

This meant that it was no longer true that there was no evidence of net benefits for screening, and a “D” no longer applied.

Therefore, the task force altered its recommendation to a “C,” which means there’s moderate certainty that the overall benefit is small. That signaled to patients and physicians that they should make an individual decision based on patient preferences and circumstances.

It’s important to note that these changes apply only to men 55 to 69. For men 70 and older, the harms outweigh the benefits, and the screening recommendation remains a “D.”

I’m sure the nuances of A, B, C and D recommendations can be confusing to the public. They can also make it seem as if experts are constantly changing their minds. But this is how we want our experts to react:

When new evidence is found, it should be added to older evidence to change our thinking when appropriate.

On the other hand, caution is still warranted when thinking about whether a man should be screened for prostate cancer. Although there is now evidence of a benefit, and its relative importance seems impressive, its absolute effects are not as persuasive.

According to these studies, a 55-year-old man has about a 0.6 percent chance of dying of prostate cancer over the next 10 to 15 years. If he is screened, that chance goes down to 0.5 percent. That’s how you get almost a 20 percent relative reduction, but an absolute reduction of only 0.1 percentage points.

Further, if a man is screened, the studies show that there’s about a 25 percent chance he will have a positive PSA test at some point. Of all men screened, about 10 percent will be found to have prostate cancer, and about 8 percent will be treated with surgery or radiation.

So out of 1,000 men screened, 80 will eventually have surgery or radiation. Three will avoid the spread of cancer to other organs. One or two will avoid death from prostate cancer. Sixty will have urinary incontinence and/or impotence. Many men will probably still think the risks outweigh the benefits.

One of the biggest concerns with screening is that too many men are treated for slow-moving prostate cancers that might never really pose a risk to their health.

A new approach, known as active surveillance, offers an alternative. Instead of receiving immediate surgery or radiation, men with lower-risk cancer are watched more closely and receive more frequent PSA tests and biopsies. If the cancer progresses, they receive interventions. About 40 percent of men with lower-risk disease were treated this way from 2010 to 2013, up from 10 percent of men from 2005 to 2009.

The goal of health care, as always, should be to maximize the benefits of care while minimizing the harms.

With this most recent recommendation, the preventive services task force recognizes that PSA screening now has more evidence to support its upside.

There’s still a large downside, though, and the ways in which we respond to positive screens should try to minimize interventions.

Aaron E. Carroll is a professor of pediatrics at Indiana University School of Medicine who blogs on health research and policy at The Incidental Economist and makes videos at Healthcare Triage. Follow him on Twitter at @aaronecarroll.

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  • Clyde Duncan  On June 29, 2017 at 6:22 pm

    For Frank Barerra, the memory is haunting. He was 48 years old when he was diagnosed with prostate cancer. He was about to have his prostate removed. The surgery was just minutes away: The IV drip had begun, the operating room was set.

    And then the call came in from the pathology department. A check of his biopsy slides showed there had been a mistake. There was no cancer.

    “You can imagine it was like waking up from a bad dream,” Barerra recalls.

    And these mistakes happen more often than many people might realize.

    Study Found Many Mistakes

    Some 1.3 million people are diagnosed with cancer every year. The person making the diagnosis is usually a pathologist who has analyzed the patient’s tissue in a lab, but has never met the patient in person.

    When researchers at The Johns Hopkins Hospital in Baltimore reviewed tissue samples from 6,000 cancer patients across the country, they found one out of every 71 cases was misdiagnosed; for example, a biopsy was labeled cancerous when it was not.

    And up to one out of five cancer cases was misclassified.

    Misjudging how fast or how far the cancer had spread could dramatically affect a patient’s care.

    “That can change whether a patient gets no treatment, vs. surgery, vs. radiation,” says Dr. Jonathan Epstein of The Johns Hopkins Hospital. “If they get surgery or radiation, which type?”

    Get a Second Opinion From an Expert Pathologist

    Mistakes can occur on any biopsy, but especially tissue from the skin, prostate, breast and female reproductive tract.

    “We really still make the diagnosis pretty much the way we did for the last 50 years,” says Dr. Leonard Zwelling of the MD Anderson Cancer Center. “It has to come down to looking at a piece of the tumor on a slide by a pathologist.”

    But what type of pathologist? Many are not specialists in the type of cancer they’re trying to diagnose.

    It becomes a problem when trying to decipher a biopsy slide. When one pathologist took a look at a slide, he saw prostate cancer. It had many of the classic features, including a small cluster of cells crowded together. But other pathologists — experts in prostate cancer — looked more closely at the individual cells and discovered they were harmless.

    “We were able to recognize this as being a ‘mimicker’ of cancer, but not cancer,” explains Epstein.

    “Often it takes a fair amount of experience, as well as technology, to make the precise diagnosis,” says Zwelling.

    Which is why more and more Americans who have been diagnosed with cancer are insisting on a second opinion from an expert pathologist.

  • Clyde Duncan  On June 29, 2017 at 7:35 pm

    My opinion on this subject is that the remedies are sometimes worse than the ailment.

    Unfortunately, the medical profession has used ‘cancer’ to scare people into surgery/chemo/radiation and now various immune therapies.

    Often surgeons rush to surgery for that is their skill set. You have breast cancer, let’s cut off your breast. You have prostate cancer, let’s cut out your prostate.

    You have testosterone that is affecting some prostate cells, let’s cut off your testicles. If you have estrogen causing you to have uterine fibroids, let’s cut out your ovaries and your entire womb. Problem solved!

    They never look to fix the real causative issues such as lifestyle, environmental toxins, diet, etc.. As lay people, we are so scared of cancer that we willingly opt for these drastic measures.

    And when these therapies do not work and we die, it is never from the awful side effects of the medical interventions or suggested remedies, it is the dreaded cancer exerting its effect despite the medical practitioners’ heroic efforts.

    The same thing applies to narcotic cocktails that older people are subjected to, in my opinion.

    Some poor senior citizen is prescribed some medication for an ailment, then another; then another for the side effects, and so on. Save Yourself!

  • Clyde Duncan  On July 1, 2017 at 3:33 am

    Do Medical Treatments For Prostate Cancer Really Work?

    If you get diagnosed with the disease, the usual treatment is surgery and/or chemotherapy and radiation.

    But the long-term success rate for these treatments is surprisingly low.

    In fact, a lot lower than what your specialist will bother to tell you!

    In Associated Press magazine, January 27, 1994, an article titled “Prostate Cancer Cure Questioned” revealed that AFTER 10 YEARS of following prostate cancer patients, only slightly more treated patients were still alive compared to patients who accepted absolutely no treatment at all.

    So if orthodox medicine really is supposed to be that beneficial for you if you have prostate cancer, then these results certainly don’t prove it!

    However, there is an easier, safer and far more effective way to prevent and reverse prostate cancer than the torturous cut-burn-poison approach.

    How about natural cures and natural prostate remedies??

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