Prostate Cancer Screening: Capitalizing on Ignorance & Fear (Part 2 of 3)

Read part 1 here »

Sadly, prior to the US Preventive Service Task Force (USPSTF) declaration of 2012, up to 40% of men with low-grade, low-volume prostate cancer were never informed about the option for Active Surveillance (AS). Most patients are prepared to rid themselves of the c-word and are ready to sign on the dotted line for surgery or radiation. Speaking from experience, I am well aware of the extra time it takes to talk men off the ledge, so to speak, along with their wives and children. Despite doing what is correct and ethical, most clinicians are not afforded the amount of time necessary to provide adequate counseling and to lessen fear. Even worse, a surgeon loses revenue and earns fewer RVUs than if he were to perform surgery. (Relative Value Units are the currency by which doctors are judged and paid for productivity from their institutions.)

Almost magically, AS programs are now being promoted by institutions nationwide. I ask, Where were they before 2012? It is certainly a fortunate turnaround. However, we must remind ourselves that being called out by the USPSTF was the catalyst for such enterprise, rather than the collective conscience of the urological community. Its members lowered serum Prostate-Specific Antigen (PSA) thresholds to 2.5, screened and biopsied men more aggressively for an ill-defined, exaggerated family history, and treated men with low-grade cancers. In short, they capitalized on fear. Even today, it is well-recognized that men in AS programs opt for surgery more often because of fear than because of disease progression.

But the Recommendation D was inappropriate. It was, as stated in their eloquent essay in the New England Journal of Medicine (NEJM) by Barry and McNaughton-Collins, like 'throwing the baby out with the bath water'! As implied, it allowed many primary care physicians (PCPs) to wash their hands of responsibility for the welfare of their adult male patients. They also acknowledge that indiscriminate screening and detached referrals to urologists were equally a failure to provide responsible care.

So the dilemma continues, as illustrated by the Audience Response System I employed during my lectures in New Orleans, 2018. I presented two patients, both age 60, and asked the large audience of family practitioners if they would screen either patient. The only difference between the two men was that one was a marathon runner who had no medical problems and took no medications, while the other had Metabolic Syndrome (MetS) - hypertension, obesity, and abnormal glucose and cholesterol levels. To my surprise, twice as many of the doctors would screen the man with MetS. The healthy runner would be 50% less likely to receive screening.

Here we have the first three major challenges of screening:

Lack of shared decision-making.

It has been shown that most doctors do not conduct shared decision-making in general and much less in the setting of prostate cancer screening. It requires time, a rapidly shrinking commodity for PCPs. To make matters worse, there is a vast variability in the respective abilities of our patients to understand the slow-growing nature of some prostate tumors, the statistics of short-term and long-term outcomes, and how these may impact him differently than his peers. Because maintaining a balance of interests changes from patient to patient, a good doctor is required to individualize this discussion without altering the content.

The comorbidity paradox.

Men who are obese, have diabetes, or have MetS are not only at higher risk of prostate cancer, but they are also for more aggressive tumors. However, these conditions decrease life expectancy in general. So perhaps the family doctors were justified to be more aggressive about screening the man with MetS. But depending on his age, his lower life expectancy would argue against the benefit of screening.

And what about the marathon runner? During the Q&A, I couldn't help but suspect that many PCPs saw themselves in this case example. The runner takes care of himself, he is slender and healthy. And indeed, it is possible to create a problem that wasn't worth creating at all. In the 2018 Journal of the American Medical Association (JAMA), Dr. Barry stated: "Screening doesn't cause cancer, but in a practical sense, it does". And yet if the runner was discovered to have a high-grade tumor, he would be the ideal surgical candidate and have the lowest risk of complications.

MetS has been associate with higher level risk of post-prostatectomy erectile dysfunction and urinary incontinence. We should ask ask ourselves: Were these men eligible for screening in the first place? Are we doing a better job of avoiding surgery in these men if they have low-grade tumors?

The Prostate, Lung, Colorectal, and Ovarian (PLCO) cancer study was a complete failure due to contamination so bad that the control arm received more cumulative PSA testing than the intervention arm. There was only one valuable observation: A secondary study by Crawford, et al found that screening only benefited patients with NO comorbidity. Even one comorbidity seemed to erase any benefit. Comorbidities were very strictly defined as any conditions which would increase risk for the top two causes of death in the U.S.

Paternalism.

Could we simply skip this discussion with any patient who has chronic bronchitis, diabetes, obesity, or diverticular disease, for example? And what about the 48-year-old who asks about screening or the 72-year-old  who will be golfing with his son on the weekend?

Should we decide a priori, with whom we shall share decision-making? Empathy for our patients can tip the scales in either direction. A rare but tragic case in our practice or our family may lead to subtle pressure to screen, while exaggerated concern and inaccurate memory of adverse effects may lead us to gently dissuade a patient away from screening.

A recent study has shown that even when patients are informed about the risks and complications of screening, one third still decide to undergo PSA testing. If among this group of men we find patients with one or more comorbidites, is it ethical to allow them to misuse this resource? Even worse, if the test is abnormal, can we ask them to avoid further testing with confidence and compassion?

Read part 3 here »