Gerald Chodak, MD


June 21, 2012

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Hello. I am Dr. Gerald Chodak from Medscape. In response to the recent United States Preventive Services Task Force (USPSTF) recommendations[1] against routine screening for prostate cancer, the American Urological Association (AUA) created a USPSTF PSA toolkit for urologists to aid in the management of prostate cancer. The toolkit includes a PowerPoint presentation, a PSA [prostate-specific antigen] information sheet, and other information, such as talking points, for urologists.

The AUA acknowledges the need for men to understand the pros and cons of screening and treatment for prostate cancer. Unfortunately, however, they provide no balanced information about these pros and cons. So, it would be a reasonable question to ask, where is this information going to come from?

Another concern is that throughout the AUA toolkit, they provide one side of the story without the other side. They don't discuss the side effects of screening and treatment. They don't talk about the limited impact that it has on outcomes. They cite some of the data from randomized trials without the data from other trials, which would create balance.

My concern is that this toolkit is more of a promotional piece than it is a balanced way of helping patients decide what to do. The AUA argues that men need to know if they have prostate cancer to decide whether they want to undergo treatment. They also talk about active surveillance as being a clear option for men, yet in the United States active surveillance is very difficult for patients to accept. A large proportion of patients can't stay on active surveillance even if they choose it.

At the end of the day, we are left with the same issue: How do you give balanced information to patients about the pros and cons? Shouldn't the AUA be providing a balanced assessment of the evidence to its members so that they can have an adequate discourse with patients?

The AUA argues that if you have a patient who decides that he wants to undergo testing, this testing should begin at the age of 40 with a baseline PSA. A high-risk patient is someone whose PSA is > 1 ng/mL. The AUA does not acknowledge that there is not a shred of evidence from randomized studies to demonstrate a benefit of PSA testing starting at age 40. All of the randomized studies that have been conducted started with patients who were at least 10 years older. This is likely to further increase the number of men being diagnosed with prostate cancer.

The AUA does acknowledge that, from the updated European screening trial, the number-needed-to-treat to prevent 1 cancer death is 37. But they don't talk about the negative side of treating 36 men who will not benefit from such treatment.

So, what does this mean? It means that people may look at the AUA and consider that the information being provided is not presented in a balanced way. Wouldn't it be best for the AUA to meet this challenge and provide a balanced presentation for its members so that they can help men decide what to do rather than coming off in a rather biased way by heralding the potential benefits without acknowledging the downside of screening?

Here we are, hoping that there is better information to provide to patients and to doctors. But sadly, the AUA has not yet provided it. Perhaps they will change that in the future. I look forward to your comments.


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