A recent ASCO publication ran a headline article about the controversy regarding PSA screening recommendations. It was the same story heard before in this and other malignancies. Some groups say screen and others say do not screen. So why does this merit discussion here? Sure, my clinical focus is on GU cancers so I pay more attention to things like this, but what makes this controversy any different than conflicting recommendations for mammograms or colonoscopies?
To me the biggest difference is that we do not know that a majority of women age 80 or older will have some undetected and clinically insignificant focus of breast cancer when they pass away of other causes. We do know that a majority of men that age passing away of completely different issues have some form of prostate cancer. We are much better at finding those clinically unimportant cancers than we used to be.
Ok…so what? We need to find a better test for diagnosis or a discriminate to help us figure out which cancers we do not need to be as concerned about. That is the basis for the conflict between the competing recommendations. We have certainly had studies looking at "watchful waiting"...sorry, "active surveillance"...with very reasonable outcomes. Can’t we tell who not to treat? The growing problem with those protocols is who can be included. The highest Gleason score you would want to monitor would be a 6, and even that is only as a 3+3. The growing issue of "Gleason creep" is making the number of men fitting these criteria less and less. I honestly cannot recall seeing a Gleason 6 recently, much less anything lower. Is "Gleason creep" more a community phenomenon? Should we have all malignant biopsies reviewed centrally? These are all questions that may beg answering.
So let’s just get a better screening test (and yes, my tongue is firmly in cheek here). Even if we had the perfect screen identified today, it will be at least a decade or more before it is uniformly accepted. I am not just thinking of regulatory and scientific issues but also of our patients' mindsets. PSA is deeply ingrained into many men’s lives. Many men (particularly in the Midwest) sit in the diner, coffee shop, or McDonald's discussing their PSAs as often as they do their golf scores. It will be a serious effort to break through that paradigm.
If I see a glimmer of light, it comes from the advances in genomic analysis. I do not think we will easily eliminate use of PSA, if at all. I do think we can have a better chance of identifying those clinically insignificant diseases by genomic analyses. It can be very cost effective to use a $2,000 test to eliminate the need for a $15,000 course of radiation or surgery, not to mention the financial and personal impact of toxicities from therapy. The NIH Clinical Center has completed a study on molecular profiling of prostate cancer but no trials are currently recorded looking at the clinical use of those data. We need to develop these studies as soon as the scientific basis exists.
To me the biggest difference is that we do not know that a majority of women age 80 or older will have some undetected and clinically insignificant focus of breast cancer when they pass away of other causes. We do know that a majority of men that age passing away of completely different issues have some form of prostate cancer. We are much better at finding those clinically unimportant cancers than we used to be.
Ok…so what? We need to find a better test for diagnosis or a discriminate to help us figure out which cancers we do not need to be as concerned about. That is the basis for the conflict between the competing recommendations. We have certainly had studies looking at "watchful waiting"...sorry, "active surveillance"...with very reasonable outcomes. Can’t we tell who not to treat? The growing problem with those protocols is who can be included. The highest Gleason score you would want to monitor would be a 6, and even that is only as a 3+3. The growing issue of "Gleason creep" is making the number of men fitting these criteria less and less. I honestly cannot recall seeing a Gleason 6 recently, much less anything lower. Is "Gleason creep" more a community phenomenon? Should we have all malignant biopsies reviewed centrally? These are all questions that may beg answering.
So let’s just get a better screening test (and yes, my tongue is firmly in cheek here). Even if we had the perfect screen identified today, it will be at least a decade or more before it is uniformly accepted. I am not just thinking of regulatory and scientific issues but also of our patients' mindsets. PSA is deeply ingrained into many men’s lives. Many men (particularly in the Midwest) sit in the diner, coffee shop, or McDonald's discussing their PSAs as often as they do their golf scores. It will be a serious effort to break through that paradigm.
If I see a glimmer of light, it comes from the advances in genomic analysis. I do not think we will easily eliminate use of PSA, if at all. I do think we can have a better chance of identifying those clinically insignificant diseases by genomic analyses. It can be very cost effective to use a $2,000 test to eliminate the need for a $15,000 course of radiation or surgery, not to mention the financial and personal impact of toxicities from therapy. The NIH Clinical Center has completed a study on molecular profiling of prostate cancer but no trials are currently recorded looking at the clinical use of those data. We need to develop these studies as soon as the scientific basis exists.
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