COMMENTARY

A Reader and Author Respond to "Prostate Cancer Screening: Why It's Not for Every Man"

Shaheen E. Lakhan, MS, MEd, AFACB, PhD, MD (c.); Michael LeFevre, MD, MSPH

Disclosures

August 04, 2008

To the Editor:

I read with interest Dr. Michael LeFevre's editorial regarding the US Preventive Services Task Force (USPSTF) stance on recommending neither for nor against routine screening for prostate cancer.[1,2] The USPSTF has a long history of eliminating unnecessary and expensive screening policies that are low yield. An example of this is their history of recommendations regarding HIV testing.

However, prostate cancer is clearly one of the leading cancers among men in the United States. Although we continue to strive for evidence-based support behind our health policies, the truth is simply that much of what we do in medicine is NOT evidence-based. It is demand-driven by the patient. Not having a recommendation for or against routine screening is irresponsible and leaves providers to treat individuals without any unifying recommendations.

In the absence of specific screening recommendations, it seems most reasonable to overdetect than to underdetect. Failure to screen all men for prostate cancer will increase the morbidity and mortality of men as a result of undetected or late detection of their cancer. Clearly, data indicate that screening has substantial benefits for patients who are aged 50 to 70 and men with increased risk such as African-American men and men with a family history of a first-degree relative with prostate cancer.[3] Thus, routine screening of ALL men may not be recommended, but at the very least there must be a recommendation for targeted screening of men according to risk.

One potential consequence of not having any screening policy is the failure of providers to actually offer testing. Typically, when routine screening is offered, a patient can "opt-in" or "opt-out" of screening. "Opt-in" is the situation where a patient is offered the test and must agree to the test to have it done. "Opt-out" is the situation where a patient is told that a test is going to be done but he has the option to refuse it. Decision-making studies continue to show that an "opt-in" policy leads to fewer tests than an "opt-out" policy. When routine screening is not recommended, testing only occurs if the provider offers it to the patient or the patient requests it.

It is therefore imperative that for any nonroutine screening, policy should be for the provider to offer the test to the patient based either on a risk-assessment protocol or on the provider's clinical index of suspicion. Failure to have such a system in place will ultimately lead to many missed diagnoses of prostate cancer. This would be very concerning given that randomized clinical trials (RCTs) indicate that men treated with early surgery have a lower mortality rate vs men not treated with surgery.[4]

I fear that in this day and age where clinicians are crunched for time and trying to make ends meet, providers will not have the time to screen for prostate cancer risk or to offer prostate screening unless the patient demands it. Thus, although the evidence may not support it, routine screening is the only way to get providers to uniformly offer screening to patients.

Shaheen E. Lakhan, MS, MEd, AFACB, PhD, MD (c.)
Executive Director
Global Neuroscience Initiative Foundation (GNIF)
Los Angeles, California
slakhan@gnif.org
http://www.gnif.org

References

  1. LeFevre M. Prostate Cancer Screening: Why It's Not for Every Man. Medscape J Med. 2008;10(5):124. Available at: http://www.medscape.com/viewarticle/574168 Accessed June 26, 2008.

  2. Agency for Healthcare Research and Quality. Screening for Prostate Cancer: What's New From the USPSTF. AHRQ Publication No. APPIP03-0003. December 2002. Available at: http://www.ahrq.gov/clinic/3rduspstf/prostatescr/prostatwh.htm Accessed June 26, 2008.

  3. Harris RP, Lohr KN. Screening for prostate cancer: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137:917-929. Abstract

  4. Holmberg L, Bill-Axelson A, Helgesen F, et al. A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer. N Engl J Med. 2002;347:781-789. Abstract

Author's Reply:

To the Editor:

I appreciate Dr. Lakhan's observations and opinions, as well as the opportunity to respond. There are 2 specific areas where we reach different conclusions.

First, the assertion that "failure to screen all men for prostate cancer will increase the morbidity and mortality of men ..." is not supported by available evidence. No well-conducted RCT of prostate cancer screening or of treatment for prostate cancer detected by screening has been published. The RCT of surgery cited by Dr. Lakhan included very few men with prostate-specific antigen (PSA)-detected cancers and a high percentage of men enrolled in the trial had stage T2 cancers.[1] These cancers are likely either biologically more aggressive or have had much more time to progress than the typical PSA-detected cancer. We cannot expect the same results over a similar timeframe with PSA-detected cancer. It is a bit ironic that the evidence cited supporting the "substantial benefits for patients who are aged 50-70 and men with increased risk such as ..." is the evidence review that the task force used to reach the conclusion that the evidence is insufficient to assess the balance of benefits and harms.[2]

Second, I think we differ on what should be done when evidence is insufficient. There are 3 different levels where we must cope with clinical decision-making in the context of insufficient evidence: clinical policies and recommendations, individual physician behavior, and patient decisions. At all 3 levels, the values of the individuals involved in the decision will often weigh heavily on the outcome. In the context of insufficient evidence, national panels often rely on expert opinion, and that opinion will inevitably be influenced by personal values and experiences. The USPSTF strives to use a process that is evidence-based and transparent and does not rely on value-laden expert opinions. The statements of the USPSTF are conclusions about the balance of benefits and harms based on evidence, and too often the evidence is insufficient to allow a scientific conclusion.

When evidence of the net benefit of a preventive service is insufficient, it should often be the individual patient's values that inform the decision. PSA screening for prostate cancer is a good example. Our job should be to inform, not to offer or recommend without information. We should provide information about what is known and unknown about the potential benefits and harms as simply and accurately as we can and help the patient make a decision that reflects his values. In the context of prostate cancer screening, this shared decision-making is the best care.

Michael LeFevre, MD, MSPH
Professor, Department of Family and Community Medicine
University of Missouri School of Medicine
Columbia, Missouri
lefevrem@health.missouri.edu

References

  1. Bill-Axelson A, Holmberg L, Ruutu M, et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med. 2005;352:1977-1984. Abstract

  2. Harris RP, Lohr KN. Screening for prostate cancer: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137:917-929. Abstract


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