Prostate Cancer Detection

“The article below was found on the medical x press blog online.  It highlights research related to DNA methylation which may play a vital role in the development of more specific biomarkers used for earlier prostate cancer detection.  In the era when the utility of the PSA test is continuously being questioned, the need for more sensitive and specific biomarkers is of paramount importance.  Miami urologists David Robbins, MD and Amery Wirtshafter, MD are experts in the field of prostate cancer detection and treatment and employ the most up to date modalities in the fight against prostate cancer.”  David Robbins , MD. 

 

Researchers discover biomarkers for prostate cancer detection, recurrence May 14, 2012 in Cancer Alterations to the “on-off” switches of genes occur early in the development of prostate cancer and could be used as biomarkers to detect the disease months or even years earlier than current approaches, a Mayo Clinic study has found. These biomarkers — known as DNA methylation profiles — also can predict if the cancer is going to recur and if that recurrence will remain localized to the prostate or, instead, spread to other organs. The study, published in the journal Clinical Cancer Research, is the first to capture the methylation changes that occur across the entire human genome in prostate cancer. Ads by Google Prostate Cancer Failures – Hope for treatment failures/ Rising PSA after treatment – http://www.panamhifu.com Cancer Treatment Options – Diagnosed w/Adenocarcinoma? Learn About New Treatment Options at CTCA – http://www.CancerCenter.com The discovery could someday help physicians diagnose prostate cancer earlier and make more effective treatment decisions to improve cure rates and reduce deaths. It also points to the development of new drugs that reverse the DNA methylation changes, turning the “off” switch back “on” and returning the genetic code to its normal, noncancerous state. “Our approach is more accurate and reliable than the widely used PSA (prostate-specific antigen) test,” says senior author Krishna Donkena, Ph.D., a Mayo Clinic molecular biologist. The PSA test detects any prostate abnormality, whether inflammation, cancer, infection or enlargement, while the DNA methylation changes are specific to prostate cancer, she says. Though the instructions for all the cell’s activities lie within the genes, whether a particular gene is turned “off” or “on” is determined by the presence or absence of specific chemical tags or methyl groups — methylation — along the underlying DNA of cells. When this process of DNA methylation turns off the activity of tumor suppressor genes, cancer develops. Dr. Donkena and her colleagues analyzed the methylation status of 14,495 genes from 238 prostate cancer patients. The patients included people who remained cancer-free after treatment, those who had a localized tumor recurrence and those whose cancer spread. The researchers found that the DNA methylation changes that occurred during the earliest stages of prostate cancer development were nearly identical in all patients. Having discovered DNA methylation patterns that could distinguish between healthy and cancerous tissue, the researchers then searched for similar biomarkers that could distinguish between patients with varying levels of recurrence risk. They found distinct methylation alterations that corresponded to whether a patient had a slow-growing tumor known as an indolent tumor, or had a more aggressive one. If physicians can determine what type of tumor patients have, they can avoid exposing patients with indolent tumors to unnecessary treatment, and can treat those with aggressive tumors earlier and more effectively, Dr. Donkena says. Dr. Donkena and her colleagues are working to develop a DNA methylation test that is more cost-effective and practical for use in clinical settings. Currently, the test relies on microarray or gene “chip” technology that assesses methylation status of genes across an entire genome. The researchers are trying to generate more economical custom microarray to specifically look at only the genes that predict the development of prostate cancer or recurrence. They also hope to develop drugs that can reverse DNA methylation in prostate cancer cells. Similar drugs are already being used to treat certain forms of leukemia. Journal reference: Clinical Cancer Research Provided by Mayo Clinic

Read more at: http://medicalxpress.com/news/2012-05-biomarkers-prostate-cancer-recurrence.html#jCp

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PSA Screening Controversy Continues

“The PSA screening controversy continues as government agencies push their cost saving agenda at the expense of the health of every day americans.”  David Robbins, MD

(Reuters) – Dr. Ned Calonge knows firsthand how hard it is to tell Americans they’d be better off with fewer routine medical tests.

A long-time family doctor in Colorado, Calonge presided over the U.S. Preventive Services Task Force, an influential government-backed panel of health experts, when it said that most women under 50 could skip their regular mammograms.

The recommendation two years ago challenged the conviction of many breast cancer patients that they survived precisely because they were screened early. It unleashed a public fury that has weighed on the panel’s deliberations ever since.

“We blew the message,” said Calonge, now president and CEO of the Colorado Trust foundation. “The nuance was completely gone.”

Two men phoned in death threats to Calonge. Protesters showed up by the offices of the government agency that supports the panel, tucked away in a Maryland suburb. The furor slowed down work on a decision to limit prostate cancer screenings as President Barack Obama fought to pass his signature healthcare law and his Democratic party faced a mid-term election challenge in 2010.

“There was a lot of pressure from above to be more careful politically and orchestrate things better,” said Dr. Kenneth Lin, who at the time was an officer at the Agency for Healthcare Research and Quality (AHRQ), a Department of Health and Human Services entity that supports the panel. “Everything with the word ‘cancer’ got shoved back.”

Calonge rotated off the panel this past March after eight years, while Lin quit AHRQ late last year in protest over the delay to prostate cancer screening guidelines that were only released in October. A White House official noted that Calonge has attributed the delay in a final decision on prostate cancer screenings to scheduling conflicts.

Their experience shows just how difficult it will be to curb spiraling costs in the world’s most expensive healthcare system by determining what screenings work, based on a rigorous study of clinical evidence, and what can lead to unnecessary and risky procedures.

“More screening is not always better,” said Dr. Christine Laine, a general internist and editor of the Annals of Internal Medicine who is not part of the panel. “That message is lost in healthcare in general.”

The U.S. Preventive Services Task Force is right on the firing line. For much of its 27-year history, it helped convince millions of Americans to get screened early for disease.

Now the panel of primary care doctors, nurses and academics has reviewed a growing body of research that shows some early screening harms more people than it helps. But it has struggled to convince patients and doctors.

In the wake of the mammogram guidelines, the rate of such screenings for women aged 40 to 69 was barely changed in 2010 compared with 2009, according to the National Committee for Quality Assurance.

“We have a public health measure that we know is effective. Why is it continually being questioned?” said Dr. Carol Lee, breast imaging commission chairwoman at the American College of Radiology.

Graphic on mammograms: link.reuters.com/zuc25s

Graphic on U.S. cancer rates: link.reuters.com/byc25s

BROACHING THE NEGATIVES

The public at large is no less skeptical. A recent Gallup poll showed that nearly 60 percent of Americans believed that standard cancer screenings – including mammograms and prostate specific antigen (PSA) blood tests – were performed often enough. Thirty-one percent thought they should be conducted more frequently. Only 7 percent said they were done too often.

“It’s extraordinarily hard to give up the notion that there’s a way to protect yourself from dying from cancer… Our goal here is to make it a matter of evidence, not a matter of opinion,” said Virginia Moyer, a pediatrician from Baylor College of Medicine, who now chairs the 16-member panel.

“Our successes are measured in positives,” she said of the public’s growing awareness of screening in the last three decades. “We are just beginning to approach the negatives.”

Burned by the experience with mammograms, the task force is looking for a better way to deliver the message, consulting with powerful consumer interest groups, hiring public relations professionals and reworking some of the language tied to its system of letter-based recommendations.

“We’re spending more time paying attention to how we say things to make sure it’s understood well,” said long-time panel member and current co-vice chair Dr. Michael LeFevre, a professor of family medicine at the University of Missouri School of Medicine. “We have no interest in being some wizard behind the curtain.”

The panel now issues its recommendations in draft form first and solicits public comment before making them final. In about a year, the public may have a chance to chime in early on the evaluation process, including posing questions for researchers and reviewing the evidence report draft used by the panel.

Task force officials concede that the comments are unlikely to change the recommended letter grade, unless they introduce crucial new evidence. But they can point to misunderstandings and help the panel better craft its message.

In late October, the panel met with consumer interest groups, including retired persons lobby AARP and the Consumers Union, to get input on how to frame recommendations that was once reserved for patient advocates.

The public’s participation has been unprecedented. The panel is now finalizing its PSA prostate cancer recommendation and public comments on the subject have reached into the thousands, LeFevre said.

WEIGHING THE EVIDENCE

The 2009 mammogram guidance from the task force was based on the panel’s assessment of new research that showed most women over 40 face a 3 percent risk of dying from breast cancer if they have not been screened. Beginning mammogram screening at age 50 and following up every other year reduced that risk to 2.3 percent, compared with 2.2 percent risk starting at age 40.

An extra decade of screening could invite harms such as unnecessary biopsies and tests, the possible treatment of non-deadly cancers and radiation. Women in their forties are also more likely to receive false positive results.

Another view of the data showed that starting screening at age 40 led to 5,000 more mammograms, 500 false positive results and 33 biopsies for every breast cancer death prevented, according to LeFevre.

“If it was just how many deaths do you cause versus how many deaths you prevent, that would be too easy, that would be simple math,” LeFevre said. “We start with somebody who feels well, and we risk making them feel worse.”

The panel voted on a “C” recommendation, which calls for patients to decide on the screening with their doctor. But when the recommendation came out in November 2009, it started with a sentence saying the panel “recommends against” routine mammograms for most women under 50, and that language triggered the controversy.

Under pressure, the task force dropped the phrase “recommends against” a month later. Its rating on mammograms remains a “C.”

The American Cancer Society questioned the evidence, saying the panel focused on gold-standard clinical trials but weeded out newer observational studies that showed better results.

“Screening is not perfect and it’s not error-free, but the question is… do you take protective measures against the unlikely probability that you develop cancer… or do you take your chances?” said Robert Smith, director of cancer screening at the ACS.

That calculation still appears to be guiding doctors, either out of concern of missing an early sign of disease or fear of lawsuits, health experts said.

“Shared decision-making (between doctors and patients) sounds nice, but in practice usually you just end up doing the test,” said Dr. Roger Chou, an internist and researcher at the Oregon Evidence-Based Practice Center. Chou authored the report on prostate cancer behind this year’s task force recommendation.

POLITICAL RUMBLINGS

The heat over mammograms weighed on deliberations over prostate cancer screening. In 2008, the task force gave an “I” recommendation on the PSA test in healthy men under 75, which meant it had insufficient evidence to make a call.

The panel usually updates its recommendations every five years, but new research published in 2009 warranted an earlier evaluation. One U.S. study showed a slightly higher risk of death for men with no symptoms of illness who received a PSA test, while European research showed a slightly lower risk of death.

Although the PSA blood test itself is innocuous, data reviewed by the task force also showed that 90 percent of American men who tested positive got treated, even if they may have been able to forego it, LeFevre said. Out of 1,000 men treated, five would die, 70 would have serious complications and 200 to 300 would be impotent or incontinent.

Given the possibility of false positives in the screening and the fact that prostate cancer can take many years to progress and show symptoms, the question is whether those risks are greater than the risk of doing nothing.

“It looks like your chance of being alive and well is greater if you don’t get screened than if you do get screened,” LeFevre said.

In November 2009, task force members voted on a stronger “D” rating on PSA tests, meaning they recommended against the prostate cancer screening in men under 75.

But the timing was poor as Obama struggled to win over a majority of lawmakers for his healthcare overhaul and Congressional elections loomed large. Once the law was passed in March 2010, it brought more attention to the task force by mandating insurance coverage of services it does recommend.

Republicans opposed to the bill used the mammogram example to show how government could intrude on life or death decisions. The task force’s “C” and “D” recommendations don’t dictate insurance coverage, but Congress quickly turned around legislation to make sure insurers covered mammograms for women in their forties.

“The thought that my work was being use as a fulcrum by one party to kill the most substantial part of healthcare legislation since I’ve been in practice? I’ve got to tell you, that’s something to lose sleep over,” Calonge said.

Officials working with the panel heard that more controversy could threaten the task force budget, up for Congressional approval. In 2010, Health Department funding for the panel was $4.3 million. This year, the agency overseeing the panel spent about $11 million on work related to the task force.

Calonge says the panel wanted more evidence of how the tests could harm healthy patients, and ordered further research. He canceled a new vote on PSA screenings in November 2010, citing scheduling problems, a decision that was widely criticized.

“In my heart of hearts I’d really like to believe that we’d delay it anyway,” without the surrounding politics, Calonge said. “We were trying to make the recommendations solid.”

That was too much for Lin, who believed the evidence was already enough to show the public was at risk. After talking with his pastor and his wife, he quit AHRQ.

“Even delaying it for a few months, much less a year, it was really relegating the men to the harms they were exposed to,” Lin said.

(Editing by Michele Gershberg, Ed Tobin and Claudia Parsons)

Prostate Cancer Surgery Miami

“This is another article which highlights the debate over PSA screening for prostate cancer.  It seems that although the US Preventative Task Force has decided unilaterally to recommend against PSA screening, government officials including President Obama and Senator Wyden have chosen to ignore the recommendations and have their PSA screened.  Senator Wyden additionally underwent surgery after being diagnosed with prostate cancer.”  David Robbins

The politics of prostate cancer

  • Sen. Ron Wyden walks to the Senate floor on Capitol Hill. | AP Photo
Sen. Ron Wyden chose surgery for prostate cancer over ‘active surveillance.’ | AP PhotoClose
By DIANE WEBBER | 12/21/10 4:40 AM EST

Sen. Ron Wyden had surgery for prostate cancer Monday, putting himself — through no fault of his own — in the middle of a debate about diagnosis, treatment and bending the cost curve.

The longtime health care advocate and Oregon Democrat was operated on by Alan Partin at Johns Hopkins Hospital in Baltimore. The cancer was caught early, and Wyden, 61, has an excellent prognosis, according to his office.

The option known as “active surveillance” (formerly “watchful waiting”) allows patients to avoid or delay surgery, radiation and chemotherapy — and the side effects that come with those treatments. Active surveillance means coming back to the doctor on a regular schedule for a blood test and examination to see if the cancer is growing. But few men choose it.

Wargo discusses active surveillance with her patients, and she considers it a good option for those who fear surgery or have other serious health problems. She is on board with the new nomenclature. “Watchful waiting sounds like you can just go disappear and not come back to see me,” she said. But she understands why many men choose surgery. “There is a personality of men who can’t live with the idea that there is something inside them that could kill them.”

Bruce Quinn, M.D., health specialist with Foley Hoag and a former official in California’s Medicare program, pointed out that, over a five-year period, active surveillance doesn’t save significant funds, because the slow-growing cancers often become aggressive and require more expensive, invasive treatment.

“It’s not the difference of $100 versus $30,000 if you look at the cost comparisons over five years. Active surveillance is more costly than people think,” said Quinn. “It’s not popular, I think, because patients must find it pretty uncomfortable to be told they have a 2-to-3-centimeter tumor that could eventually blow up and kill them, and we’re just going to watch it. Men say, ‘Just get the damn thing out!’”

Wargo and Quinn both noted problems with the prostate-specific antigen test that is the screening tool used for diagnosis. A normal level in one individual might be abnormal in another, and doctors need to track changes in the level over time to approach any kind of accuracy.

“You really have to look at each patient individually,” said Wargo. “A PSA level of 4 is normal in an older patient, but it is completely unacceptable in a 47-year-old. You can have a low level and still have aggressive prostate cancer.”

Complicating matters is the fact that no test accurately predicts who will get the aggressive, deadly form of the disease and who will get a slow-growing, non-life-threatening form. Quinn points to Medicare reimbursements as part of the problem.

In choosing surgery over what used to be called “watchful waiting,” Wyden took a path that many men take when faced with a prostate cancer diagnosis. But increasingly, that path is questioned in the era of health care reform, as cost-cutting is pitted against personal choice.

Doctors acknowledge that the cost-cutters have a point but bristle at the intrusion into the physician-patient relationship.

“It is well and good for statisticians to say, ‘This is the patient who doesn’t need to be treated,’” said Heather C. Wargo, a urologist practicing in Mount Laurel, N.J. “But when I am sitting with a patient, looking him and his spouse in the eye, it is very difficult to say, ‘I’ve been accused of overtreating, so I’m not going to treat you.’”

The U.S. Preventive Services Task Force, the body that sparked a firestorm when it said that most women do not need an annual mammogram until age 50, was set to vote on new prostate-cancer-screening recommendations last month. Instead, the panel canceled its November meeting, citing “scheduling conflicts.”

Kenneth Lin, professor and family physician, quit the task force in protest. “Politics trumped science this time, as it has in the past, and may at times in the future,” Lin wrote in his blog, where he linked to a news account of the mammogram controversy.

Rep. Debbie Wasserman Schultz (D-Fla.), who had breast cancer, told POLITICO that the task force “seems out of touch with reality.”

“I think that organization really undermines its credibility, not necessarily among the scientific community but for the general public,” Wasserman Schultz said, noting that there were no cancer experts on the panel when the breast-cancer-screening recommendations were made.

Yet statistical analysis like the task force’s research has some of the greatest potential to save money on health care spending.

Prostate cancer is ripe for study. Researchers question whether it is being overdiagnosed and whether too many surgeries are being performed on tumors that would never become dangerous.

“The Medicare fee schedule is around $20 for the PSA test, and it is just frozen there,” said Quinn. “It’s really hard for companies to do the trials that they need to do to come up with a more effective, more precise prostate cancer test with this artificially very low fee.”

Mara Aspinall is CEO of On-Q-ity, a company working on new diagnostic tests that have the potential to identify rare cancer cells circulating in the bloodstream, long before they are prevalent enough to be picked up as tumors on MRI and CT scans.

Aspinall said the Medicare fee schedule is a problem for her new technology. “In the laboratory, the more steps your process has, the more you’re paid,” she said. “This was a useful construct some time ago, but it has not kept pace with technology. We now can have one really big step to replace 10 small ones. It’s an incredible disincentive.”

While Aspinall argued that better diagnostic tests could bring more clarity and potential cost savings to prostate cancer treatment, she emphasized that tests can’t replace the doctor-patient dialogue.

“It is essential that the decision on how to proceed — even in the era of diagnostics — needs to continue to be an educated discussion between the physician and the patient,” said Aspinall. “We want to bring more information to the equation.”

Wyden will no doubt be helpful in bringing more information to the equation as he recovers from his disease. He started working on public health issues as a young lawyer when he founded a legal aid society for the elderly and Oregon’s first chapter of the Gray Panthers. During health care reform, he was the architect of the Healthy Americans Act, which would have radically changed health care from the employer-based system, and now he is co-sponsoring a bill that encourages states to innovate on reform implementation.

“If anything is taken away from my experience, I hope it is the importance of getting routine physicals,” Wyden said as he was disclosing his disease last week. “One in six men will be diagnosed with prostate cancer during their lifetimes. Early detection is critical to catching this disease when treatment is most effective.”

New PSA Screeing Recommendations May Cost Patient His Life

Dr. Deepak A. Kapoor is president of Advanced Urology Centers of New York and president of the Large Urology Group Practice Association.

Recently one of our patients made a decision that may well cost him his life. John Smith (not his real name) is a 51-year-old who had an elevated prostate specific antigen (PSA) during a routine prostate cancer screening exam. After a blood test confirmed our concerns, he had a biopsy — and, though he had no other symptoms, the patient was found to have multiple areas of high-grade prostate cancer. After obtaining several opinions, he scheduled minimally invasive robotic surgery to have his prostate removed.
But then, the United States Preventive Service Task Force issued recommendations that PSA screening is unnecessary, saying that asymptomatic men whose cancer is detected via screening are unlikely to die from their disease. Based on this, Smith canceled his surgery. And despite our attempts to explain that ongoing observation is not appropriate for his aggressive disease, he is adamant in his refusal to have treatment.
The true tragedy is that the task force, which is chaired by a pediatrician and includes no specialists who treat prostate cancer, made this recommendation based on controversial and contradictory studies and inexplicably ignored data on prostate cancer incidence and mortality.
In 2009, this same group suggested mammograms were unnecessary for women younger than 50, and recommended against teaching women to do breast self-exams. Due to public outrage, these recommendations were almost immediately retracted. To avoid further embarrassment at that time, the panel decided not to fully release its prostate cancer screening recommendations, and then just issued a limited opinion suggesting PSA screening was not warranted for patients older than 75. Since then, only one additional screening study has been published, which demonstrated a 44 percent decrease in prostate cancer death rates among Swedish men who received screening compared with those who did not.
Without question, prostate cancer can be a slow-growing disease for some men. But it is fatal for many others, with the National Cancer Institute predicting nearly 34,000 prostate cancer deaths this year. It is the second-leading cause of cancer deaths for American men, after lung cancer.
But we have made enormous strides in treating this disease. Before PSA screening, the 10- year survival for prostate cancer was 53 percent; it’s now over 97 percent. Since the advent of widespread PSA screening in the early to mid 1990s, the death rate from prostate cancer has decreased by nearly 40 percent, while during that interval the incidence of prostate cancer is virtually unchanged. We are diagnosing prostate cancer earlier, and saving lives.
The task force suggests that no one without symptoms be screened, but every urologist knows this is a grave mistake. By the time prostate cancer is symptomatic, the opportunity for cure is lost. Screening, though not perfect, provides patients with information that they can use to make the best decisions for themselves. To suggest that no man have this information because of concerns regarding treatment that they may never receive is a scientific bait-and-switch of the worst order.
Shortly after release of the task force recommendations, President Barack Obama, after discussion with his doctor, chose to have PSA screening. These recommendations open the door for government and third-party payers to stop covering this test, meaning that the average man may be unable to make that same choice. And men like Mr. Smith who don’t show symptoms might never be able to make an informed decision about treatment until it is too late. Every patient should be able to do just what the president did — make a screening decision with his own doctor, and not have that choice made for him by insurance executives or government bureaucrats.
Massive public outcry saved breast cancer screening for women, and studies show that screening efficiency for prostate cancer is similar to that for breast cancer. Those of us concerned with men’s health must make our voices heard to prevent these premature and ill-advised recommendations from ever being enforced. That will help save the lives of thousands of Mr. Smiths nationwide.

2,250-Year-Old Mummy Had Prostate Cancer

2,250-Year-Old Mummy Had Prostate Cancer Researchers find telltale signs of modern day man killerBy Greg Wilson | Wednesday, Nov 2, 2011 |

An ancient Egyptian had prostate cancer, according to recent testing. advertisement Testing on a 2,250-year-old mummy proves prostate cancer is nothing new. A mummy at the National Archaeology Museum of Lisbon had a pattern of tumors between its pelvis and lower spine, telltale signs of the modern day man killer. “The bone lesions were considered very suggestive of metastatic prostate cancer,‭” ‬researchers wrote in a paper on the mummy published in the International Journal of Paleopathology. The man beneath the gauze wrapping was between 51 and 60 years old when he died around 285 B.C. The mummy was analyzed by a powerful Multi-Detector Computerized Tomography scan. Researchers believe the man died a slow and painful death. “It is the oldest known case of prostate cancer in ancient Egypt and the‭ ‬second-‬oldest case in history,‭” ‬radiologist and researcher Carlos Prates said. Paula Veiga, an Egyptologist, told Discovery News the case proves that cancer, believed to be largely environmental, existed in ancient Egypt. “This study shows that cancer did exist in antiquity,‭ ‬for sure in ancient Egypt.‭ ‬The main reason for the scarcity of examples found today might be the lower prevalence of carcinogens and the shorter life expectancy,‭” ‬said Veiga The earliest known case of prostate cancer was found in ‬2007,‭ ‬by researchers investigating the skeleton of a‭ ‬2,700-year-old Scythian king who died in Siberia.

Survey of Top Doctors Finds Widespread Support for PSA Screening

 

 

Survey of Top Doctors Finds Widespread Support for PSA Screening

Top Doctors strongly disagree with government task force proposal to drop use of prostate cancer test

October 28, 2011 RSS Feed Print

 

PSA screening for prostate cancer has been a hot topic in the urology news not only for patients in Miami, but throughout the country.  The U.S. Preventive Services Task Force’s decision to downgrade the recommendation for PSA screening for prostate cancer has not been supported by the either polled urologists or primary care physicians.  This article highlights topics and opinions in the current debate over PSA screening for prostate cancer.”

In an exclusive new survey of Top Doctors conducted by U.S. News & World Report, virtually all responding urologists and more than 60 percent of internal-medicine specialists rejected the recent proposal by a high-level government advisory committee to end routine PSA testing, which is meant to catch prostate cancer early.

An estimated 20 million men a year undergo PSA screening, which determines the blood level of a protein called prostate-specific antigen; nearly 250,000 of them are diagnosed with prostate cancer. The proposal, issued by the U.S. Preventive Services Task Force, advises doctors not to screen patients with the PSA test unless they have symptoms that are “highly suspicious” for prostate cancer.

“If you argue that you should not use PSA testing at all in [men without symptoms], you’re essentially saying you don’t want to find prostate cancer at a curable stage,” says Dr. Samir S. Taneja, director of urologic cancer at NYU Langone Medical Center and a responder to last week’s U.S. News survey.

The government task force found little evidence that screening men with the PSA test significantly reduces deaths from prostate cancer. Whatever small benefit there might be, the task force concluded, is outweighed by the risk of an incorrect diagnosis or unnecessary procedure leading to death or complications. About a third of men treated for prostate cancer suffer urinary incontinence, impotence, or both, and about 1 in every 200 dies within 30 days from complications of surgery.

Doctors have debated the risks and benefits of the PSA test since 1994, when the Food and Drug Administration approved it for cancer screening. Even the test’s supporters acknowledge that it is inherently imprecise. A high PSA level may indicate the presence of a tumor—or it may not. Nor is a low PSA level necessarily an all-clear. Moreover, the test cannot distinguish between a typical tumor, which grows so slowly that the threat is minimal, and one that is aggressive and potentially lethal.

To determine whether some of the nation’s best doctors agree with the task force’s proposed recommendation, U.S. News surveyed more than 600 urologists and internists who are recognized as Top Doctors by U.S. News and Castle Connolly Medical Ltd. More than a third of the physicians responded. (For a breakdown of the questions and responses, see Behind the U.S. News Top Doctors Survey on PSA Screening.)

About 95 percent of the responding urologists felt that doctors should continue to advise men starting at age 50, when testing typically begins, to have PSA screenings as part of a routine physical exam, contrary to the task force’s recommendation. They included themselves in that group; 97 percent indicated they would be tested starting at 50. The internists were less unanimous—about 40 percent agreed with the proposed recommendation to end routine testing. But 72 percent of the responding male internists indicated that they themselves would have the test starting at age 50.

The vast majority of the survey respondents sent U.S. News comments as well. “Can you put a price on being saved from dying of cancer?” wrote Dr. Ernest H. Agatstein, a urologist with Paletz Agatstein Urology Medical Group in Downey, Calif.

PSA screening is “an awesome test,” wrote Dr. Richard J. Macchia, a urologist at Cleveland Clinic Florida in Weston. “When I was young,” he went on, “almost all the prostate cancer patients I saw had metastatic disease at diagnosis. Now, in patients who have their PSAs checked, I almost never see metastatic disease at the time of diagnosis. We can cure metastatic diseases only rarely.”

Task force member Dr. Michael LeFevre, professor of family medicine at the University of Missouri School of Medicine in Columbia, says the impassioned backlash against the draft task force recommendation is unsurprising. “When science doesn’t give us the result we want, it’s pretty unusual for the medical and patient communities to turn on a dime and say, ‘We were wrong,’ ” he told U.S. News.

The task force reviewed over 8,000 summaries of research studies related to prostate cancer screening and treatment. Many were eliminated because of major flaws. The strongest evidence came from two large trials that examined the impact of prostate cancer screening on death rates.

The first was a U.S. trial of nearly 80,000 men between the ages of 55 and 74. The men were divided into two groups: One had PSA testing and a digital rectal exam and the other had only a rectal exam. The study found that screening boosted the number of diagnosed cancers by 20 percent, but also that diagnosing the additional cancers did not reduce overall death rates over 10 years of follow-up.

The second study, involving 182,000 men and carried out in Europe, found that PSA screening reduced the number of cancer deaths by about 6 or 7 for every 10,000 men tested. Based on these results, the task force concluded, 48 men would have to be treated to prevent one prostate cancer death, exposing 47 men to the dangers of treatment.

Dr. Patrick Walsh of Johns Hopkins Hospital, a pioneer of radical prostatectomy—surgical removal of the entire prostate gland—takes issue with the task force assessment. He points to American Cancer Society statistics that show a 40 percent decrease in prostate cancer deaths since 1994, a decline that he attributes to the introduction of PSA screening.

Dr. LeFevre counters that the downward trend in prostate cancer deaths began before the PSA test was widely adopted, which suggests that the test wasn’t the driving force.

Dr. Alan Wein, chief of urology at the Hospital of the University of Pennsylvania, told U.S. News in an interview that the two sides may not be as far apart as they seem. On the one hand, he says, “mortality from prostate cancer has decreased, and it happens to coincide with PSA screening. And there’s no question that, before PSA screening, it was common to see people come in with metastatic or very advanced local disease. You rarely see that now. It may not be cause and effect, but those are the facts.”

On the other hand, says Wein, there’s also no question that too many patients are encouraged to seek radical prostatectomy or radiation and too few are informed about a third option known as watchful waiting, in which doctor and patient use periodic PSA tests, frequent physical exams, and biopsies to track a tumor’s growth and decide when, if ever, to pursue aggressive treatment.

“I would hope that the whole issue helps urologists understand that we have to be forthright with patients about our expectations for treatment and those circumstances when it’s most reasonable to watch and wait,” Wein says.

The U.S. Preventive Services Task Force recommendation, which was made public October 11, is not final. It could change after the medical community and the public submit formal comments.

President Barack Obama Receives PSA Test

Despite the recent controversial recommendation by the USPSTF against routine PSA screening, President Barack Obama recently received a PSA test to screen for prostate cancer.

AACU Members and Allies: President Barack Obama recently received a Prostate Specific Antigen test to screen for prostate cancer during his yearly physical. White House physician Dr. Jeffrey C. Kuhlman’s report, which was released October 31st, said the test was performed after the President made an ‘informed patient request.’ The U.S. Preventive Services Task Force recently recommended against PSA-based screening for prostate cancer earlier this month, which they said can do more harm than good. Yet the commander-in-chief felt it was important enough to ask for the test personally. This begs the question: If the President of the United States who has the Country’s best doctors and most current information at his disposal, chooses the PSA test, why shouldn’t all men have the same choice? Obama is fortunate to have the means and knowledge to ask his doctor for a PSA test but if the USPSTF recommends against the test, millions of other men might not be as lucky. The test is not perfect but is currently the easiest and cheapest method of detecting prostate gland abnormalities. We urge you to take action to preserve patients’ choice and save lives. Please be sure to submit comments to the USPSTF as soon as possible before Nov. 8. Links to the USPSTF comments form, as well as pre-written letters to Congress and the media are available at the AACU PSA Test Action Center. Visit the site often to review frequently updated information and resources. Thank You! Click the link below to view this message on the web: http://www.votervoice.net/link/target/aacu/QgBQWifJ.aspx You have received this message because you have subscribed to a mailing list of American Association of Clinical Urologists. If you do not wish to receive periodic emails from this source, please click below to unsubscribe.