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Oct 29th 2014

A Response to the Canadian Task Force on Preventative Health Recommendations on PSA Testing

A Response to the Canadian Task Force on Preventative Health Recommendations on PSA Testing

Monday, the Canadian Task Force on Preventative Health Care (CTFPHC) issued a statement on the use of the PSA test in screening men for prostate cancer.  In summary a blanket recommendation was made that PSA screening should not be offered across all age groups.  In many ways this is not new. The debate over the role of PSA (prostate specific antigen) in prostate cancer screening has raged on for many years.  I have previously written about this and it has been also a subject of similar task force recommendations south of the border. The CTFPHC prominently notes that it was endorsed by the College of Family Physicians of Canada. No significant input from credible bodies representing specialties that actively treat prostate cancer was considered. 

 

First some background. Over the course of one's life it is estimated that up to one in seven, perhaps one in six men in Canada will be diagnosed with prostate cancer in their lifetime. It is equally true that prostate cancer is a common source of cancer mortality in Canadian men.   PSA is a protein normally produced by prostate cells. It is expressed both by benign and malignant cells. Its use in oncology has been guided by the notion that men with prostate cancer tend to make more PSA relative to other causes. It has been used in prostate cancer detection and monitoring since the late 1980s. 

 

There is no doubt that the use of PSA helps clinicians detect prostate cancer early. The dilemma arises from the fact that prostate cancer is generally a very heterogeneous disease. On the one hand men with a relatively indolent (‘benign’) cancer will likely die from other causes. At the other extreme there are men with much more significant cancers who will succumb to the disease. Prostate cancer can be relatively harmless but also is the same disease that afflicted prominent Canadians such as Pierre Trudeau and Jack Layton. An ideal screening test is one that will detect a cancer at a point where intervention will alter the natural history of the disease and where that treatment can be performed safely and in a cost effective manner.  By the definition laid out by statisticians and epidemiologists PSA is not a great screening test on its own.  Thankfully those two groups don't actually treat men and their families with prostate cancer

 

Monday’s new guidelines start with the premise that early detection will lead to a cascade of both potentially harmful tests and overdiagnosis. It is certainly true that many men  diagnosed with prostate cancer do not need to be treated. Treatment can be very effective but can negatively impact urinary and sexual function. It is the challenge of clinicians in that scenario to help patients understand through comprehensive counselling why their particular cancer may best be left alone. They may be older, have significant other medical issues or simply have minimal disease on biopsy. 

 

I think the CTFPHC recommendations are both lazy and misguided.  In part they are an attempt to manage this overdiagnosis phenomenon and make an assumption that active therapy always follows. However, many men will ultimately present with more advanced disease, well beyond the ability to be cured, if we abandon any attempt to detect for prostate cancer.  Current thinking, much of which has been pioneered here in Ontario under the leadership of my great mentor Dr. Laurie Klotz reflects the importance of separating diagnosis from treatment. A positive biopsy is not a binary outcome. Information that includes the grade and volume of cancer can provide much insight into the potential aggressiveness of the cancer.    Certainly known risk factors such as family history and ethnicity remain important. However, in my own personal experience over the years many men I have looked after with significant disease, often in their early 40s, have no previously known risk factor.  

 

How do we find these men? The trick probably lies in using a multifactorial approach to risk assessment. The PSA test alone is a simple blood test, which can help guide who may or may not be at risk.  Establishing a baseline that is particularly low early in life may reassure a man that perhaps he does not need to have the blood test done every year.  These men perhaps could have a PSA done three or four times over the course of thirty years.   On the other hand a man with a PSA that is not negligible in his early 40s (more than 1) should probably be followed more closely. This kind of ‘smart screening' that also takes into account other risk factors and how PSA changes over time can only be performed if we have some historical sense of what an individual patient's PSA previously was.  A baseline is essential. This will not happen if we abandon the PSA test.  

 

The August 2013 Melbourne Consensus which reflects the input of numerous thought leaders from around the world represents I think the best sense of how we should use PSA in 2014. The Canadian Urological Association in response to Monday’s recommendations published a very reasonable approach that also reflects much of this thinking.  This is what we should be telling Canadian men. 

 

The CTFPHC recommendations may be a well-intentioned effort to provide guidelines on PSA screening but in the clinical real world it will be mistaken as a statement on PSA testing.  Confusion at the primary care level will not make any distinction.  PSA will simply stop being drawn. That will be a disaster. This simple blood test by itself does not cause any harm. Over the last three decades we have significantly reduced the mortality rate from prostate cancer. It may not be long before we see a generation of men ultimately present with advanced disease and once again wonder how did we get here. The 1980s textbooks of my medical school days fully described only 20% of prostate cancer's being curable at the time of diagnosis. We may yet get there again

 

 

Comments

Posted: October 29, 2014

By: bob

As a survivor , because of early detection and early treatment , I can whole heartedly support this articles conclusions .... you never want to be diagnosed in the later stages of PCa !

Posted: October 29, 2014

By: Scott Hackney

Rajiv, read the news and expected to see something from you. Although I've read only an infinitesimal fraction on PSA testing relative to you, it was mind boggling and disappointing to read the task force's recommendations. Is there anything I can do to help reverse this?
S

Posted: October 29, 2014

By: Thomas Tra

I totally agree with Dr. Singal, screening PSA for men in there 40s is a good way to direct the volume of the disease down. And if their PSA is low for the first one they can be retest again in 2 or 3 years. In my case I got diagnosed prostate cancer when I was 41 without any symptom of the disease and my state for T3b. What if I wait until I get to 50 years old? And the blood test does not harm anybody even if the PSA was higher then normal a bit but then it will get monitored.
Thanks for the Blog.

Posted: October 29, 2014

By: W.D. Wilson

My diagnosis with prostate cancer was the result of regular PSA tests , digital rectal exams and , finally , a biopsy . To argue that any one of these tests is unnecessary does not make sense to this patient.

Posted: October 29, 2014

By: Shawn Whatley

Thanks for writing this, Rajiv! I really appreciate you providing perspective. The new recommendations seemed to rule out PSA, period.

Keep writing!

Shawn

Posted: October 29, 2014

By: Will O'Hara

I had PSA testing done every year, along with rectal examinations. When the PSA levels spiked I had a biopsy that indicated cancer. I had surgery. Thanks to Dr. Singal, I'm well and cancer free.

I completely agree that doctors should be telling men to get regular PSA tests. I tell everyone I know to do that. I've seen men die from prostate cancer that could have been detected early and cured.

Posted: October 29, 2014

By: Shaun Clarke

I read the Task Force conclusions and was stunned ... lazy , inept and callous were the words that came to mind! I was in my 40's, with NO symptoms and no history in my family when the PSA alerted my MD to the advanced state of my cancer. I'm still here because of that PSA test !

Posted: October 29, 2014

By: Warren

Thanks for the great writeup. My aggressive prostate cancer was detected by my GP with a digital rectal exam at age 40. Subsequent PSA tests with significantly increasing velocity showed that a biopsy was in order. The biopsy was positive with detected Gleason 7 (was increased to Gleason 9 after the prostatectomy). I would have been dead by now (I'm 48) if I wouldn't have been diagnosed early. PSA was a big part of that, but so was my GP testing me at 40 with a DRE.

Early detection is very important. It doesn't mean treatment needs to happen, but in many cases, if you are getting it young, it probably is more aggressive and will need to be treated.

The article was indeed very lazy and inaccurate.

Posted: October 29, 2014

By: Dr. Ryan Groll

Rajiv - As you know I share your well-articulated thoughts. The failure of the Task Force to consider the burden of metastatic disease and only the potential morbidity of treatment is a huge oversight. Furthermore, ignoring the fact that almost all men with low-risk cancer are currently offered active surveillance first-line (and likely weren't at the time most screening evidence was compiled), invalidates the argument of overtreatment.

The urologist is the gatekeeper to biopsy and treatment. Both of which I approach with careful consideration of many patient and disease factors and of course, complete involvement of the patient himself.

The PSA is a risk estimate, albeit an imperfect one. The key is the interpretation of the result and the thoughtful consideration of risk and benefit for each individual. A blanket statement calling for complete PSA abandonment is dangerous and a disservice to men, especially when no alternative exists.

Family doctors will understandably heed these recommendations (it will be a lot less complicated for them to do so, and the CTFPHC has provided justification) unless experts in the field get our message across.

Ryan Groll
Urologist

Posted: October 29, 2014

By: Rick

It was a PSA test that first alerted me of prostate cancer. The test was a red flag that further investigation should be done, after digital rectal exams and a biopsy I was graded with a T2a cancer. The cancer was aggressive enough that treatment was my next option. I had no symptoms without a PSA test I wonder at what stage my cancer would have been discovered.

Posted: October 29, 2014

By: Denis Saudino

Diagnosing P.C early is key,to survival and very important quality of life.
while P.S.A. may not be 100% accurate, I wonder what medical test is...
It has proven itself for the last 30 years, and who wants to live with Cancer in your body not knowing if or when it will turn for the worst.
Not I. with quality of life, who wants to live with having to go to the washroom so often you may as well live in one, because no sooner do you think your done, you have turn around again,and try getting a good nights sleep.
remember also that P.S.A. tests are not free in Ontario unless you have previously had P.C.
Personally I would rather put my faith in a specialist like Dr Singal than the College of Family Physicians of Canada.

Posted: October 29, 2014

By: bob

Rajiv - again a voice of sanity! At age 62, I regularly get the PSA test as a tracker/indicator to have a conversation with Doc and specialist, if required. I am also required to purchase this test myself, and so it is my choice to undertake or not. Diagnosis and treatment are completely separate [ at least for rational people] and it strikes me as odd that the "esteemed Task Force" would suggest that medical practitioners don;t know that difference. it's MY prostrate, MY $25 and MY future, and thankfully My decision to act. My next [ annual ] screen is set up for later November....I am going

Posted: October 29, 2014

By: Gilbert

I am being tested on a regular basis- have had 3 biopsies
and have been on Watchful waiting for more than 3 years.
I place full confidence in my cancer doctor and will follow
his instructions. I am 76 years old and feel fine - no side effects
hopefully this continues.

Posted: October 29, 2014

By: Gerry Jesberger

In my opinion, this is yet another cost cutting measure on behalf of Health Canada. More testing, more expense!!!!! We are not talking about the lives of people here we are talking economics!!!

Posted: October 29, 2014

By: Gerry Jesberger

The PSA testing is a costing cuttting measure for those in lower income groups.....another indication that those with money can live for ever....or almost, and those without money die early.

Posted: October 29, 2014

By: Gerald mcgarrigle

My biopsy was negative about 5 years ago,but I had a high P.I.N.I read online that if a person has a high P.I.N.,then there was a high chance of that person getting prostate cancer in 5-10 years.Is this correct?

Posted: October 29, 2014

By: Peter

My father was diagnosed 25 years ago with the PSA test. His number was 15. He had the surgery and has just turned 80. He had no symptoms and the DRE revealed nothing. My uncle died 10 years ago of prostate cancer because he refused to get checked. Given my family history I started getting check annually with both DRE and PSA test. At age 51 my doctor said my PSA was going up but DRE and Ultrasound showed no abnormalities. I also had no symptoms. She referred me to Dr. Singal who did a biopsy and found cancer significant enough to warrant surgery. I had the surgery 1 year ago today and am currently cancer free. I feel that this is because of the PSA test, and of course Dr. Singal. Please do everything to stop these misguided individuals from claiming PSA tests are not needed.

Posted: October 29, 2014

By: Neal Kelly

It was a PSA test that led to the detection and treatment of my prostate cancer! I had had both digital rectal exams (DRE) and PSA tests done at my bi-annual medicals over several years. In Spring 2011 (at age 64) my DRE was normal but my PSA showed an increase over previous year's readings. As a follow-up my GP scheduled another PSA test in late summer 2012 and it showed yet another increase. He referred me to Dr. Singal and a subsequent PSA test showed yet another increase. A biopsy in early 2012 came back negative. Subsequent PSA testing showed continued increases and a follow-up biopsy in fall 2012 detected a prostate cancer that required treatment. After surgery in January 2013, I am cancer free. It is clear that the DRE did not detect the cancer and even the initial biopsy did not! It was only the PSA test that kept the focus on finding the cancer allowing an appropriate decision to be made about treatment.

Posted: October 29, 2014

By: Victoria

Had it not been for the PSA test a very dear friend of mine would not be alive today. Thank you for writing this, Dr. Singal. Please don't stop advocating on this issue. We need more courageous voices like yours to step up in the medical community. The precious lives of our lived ones are at stake!!

Posted: October 29, 2014

By: Charles McKee

Having Gleason 10, 8 & 7 after "nothing to worry about" DRE by GP, Urologist, Resident and Biopsy technician the only reason I am alive 12 years later is because of regular PSA screening.

I do not consider the recommendations by the Task Force to be just negligent in my opinion they are criminally negligent. If GP's follow them they are professionally negligent and the lawyers will have a field day as they wipe out the doctor's insurance fund.

Posted: October 29, 2014

By: Brian

A well reasoned overview that appropriately avoids emotion and hyperbole with a welcome bias towards logic and experience.

Mark Twain perhaps said it best; "Facts are stubborn things but statistics are pliable."

You may well be a better writer when you are tired after a long day.

Are appointments available after midnight?

Keep up the good fight.

Posted: October 29, 2014

By: Nick Orlando

Better safe than sorry. Early screening by PSA blood test saves lives. Without early detection my diagnosis may have been much worse. Arguments that PSA testing may lead to unnecessary tests is a short sighted view of the world. There are other parts of the health care system where cost savings can be achieved.

Posted: October 30, 2014

By: Ed Collis

Another example of Eddy's Theory of Legislation which states:
"Legislation can only be written by those who know absolutely nothing about the topic."

Posted: October 30, 2014

By: John Keenan

This survivor finds it truly astonishing that the CTFPHC would come to such a conclusion. For starters they might have checked out the Melbourne Consensus on Prostate Cancer Testing that deals so admirably with the confusion and controversy of PSA testing.
Keep up the good work Rajiv.

Posted: October 30, 2014

By: Jack

Rajiv, you and I have discussed this issue on several occasions over the past six years since you guided me though the decision making process after PSA testing and resulting biopsy revealed a Gleason score of 7. I have been cancer free since and actively promote PSA testing with both my son and son -in-law who are both in their 40's and so far, so good. Your article is on point to a story that needs to be reinforced. Keep up the good work.

Posted: October 30, 2014

By: Aaron

Thank you on my own personal behalf.
And thank you for the message that should be getting out there to those innocent men who might be walking around with prostate cancer and at the moment have no idea about that!
You know that I have been involved with my support group (PCCN-Toronto) for 14 years and we have unfortunately seen on too many occasions the results of men NOT getting a PSA blood test AND a DRE test - they are diagnosed with advanced disease! We have met and continue to meet these men all too often. And too many of them have told us that they never went for the PSA test because their family doctor dissuaded them from doing so, or they read similar reports such as the CTFPHC put out on Monday.
I'm never naïve enough to believe that many of these same men wouldn't have been diagnosed with prostate cancer anyway, but by having a PSA test, they certainly would have received a diagnosis which was much more treatable and curable,
We all must continue to advocate FOR PSA screening to Canadian men: I have no idea what shape I'd be in today if I wasn't going for this blood test back in the late 90's and hadn't been diagnosed and treated very early in 2000. The same can be said for every man who belongs to prostate cancer support groups across this land.
Thank you again for continuing to get this "correct message" out to men.

Posted: October 30, 2014

By: Ed Long

After your talk in Thunder Bay, we had 185 men receive free PSA testing at "Men Make It Happen". You thoughtfully presented scientific and antidotal information to us. This is another example. I hope it helps change the recommendations before they review it in 5 years.

Posted: October 30, 2014

By: Tom Little

As a Prostate Cancer survivor because of PSA testing, it is inconceivable to me that this simple test should be eliminated. It must be that the people on the task force are immune to Prostate Cancer and therefore do not need PSA testing to possibly save their lives? I wish them luck because they will need it.

Posted: October 30, 2014

By: Ed Dakin

The very thought that my "aggressive" average Gleason of 8, prostate cancer, picked up by a random PSA of 17.5, would now be metastatic, makes me cringe!
18 months ago my biopsy led to surgery, local external beam radiotherapy, for suspect margins, and now undetectable PSA gives me, and many others a great sense of gratitude for Dr Singal and his work.
All four of my colleagues at work, that have had Prostatic cancer, have had Vasectomies, which was paid for by OHIP. Whereas we paid for our PSA blood tests! Perhaps Vasectomies should be a reason for OHIP covered routine PSA testing?
Testosterone suppression is not a benign, and questionable effective prophylactic treatment! Why is there not testing for receptor sites, in our prostate cancer, as there is Oestrogen receptor site testing in breast cancer?
The issue of PSA testing has been reduced to "put your head in the sand, and it will go away"!
Keep up the good work, Rajiv.

Posted: October 31, 2014

By: Wayne Johnson

This debate reminds me of the similar one surrounding psychological testing as a personnel selection tool. There are many who would look at a single test score and make their hiring decision based on that alone. Ridiculous, of course! A well founded hiring decision is based on a wide variety of factors.

Similarly, as Dr. Singal rightly points out, a PSA test is but one data point among many, it is not the sole determinant.

We need to look at the bigger picture, not just a "few pixels"

Thank heavens we have broad thinkers such as Dr Singal

Posted: October 31, 2014

By: Peter Crosby

I was diagnosed with prostate cancer 12 years ago. The diagnosis came from a digital rectal exam by my family physician followed in short order by a PSA test and a biopsy by Dr. Singal. I was 59 years old. The rectal exam revealed an asymmetric enlargement of my prostate with a change in texture, already alarming, and my PSA was over 20. I had a Gleason number of 8 in the biopsy. All of this made it very clear I had a serious prostate cancer issue and I was in surgery a few weeks later.
To this day I regret that I did not have regular prostate check-ups earlier and regularly because by the time I had surgery the cancer was no longer encapsulated. Had I been diagnosed a year earlier I might have had a cure instead follow up treatments of hormone suppression and radiation. Don’t misunderstand me. With all the nasty side effects of the treatment I have been living a full and active life and I am grateful for the contribution of medical science.
Nonetheless my outcomes could have been better with earlier intervention and I will be encouraging my sons to be followed closely when they hit 40. I have a brother and a first cousin with prostate cancer. As far as I am concerned while I support caution in the interpretation of PSA results I see great value for my sons in establishing a baseline and monitoring change. The rectal exam in conjunction with the PSA is also important in my opinion. Like Dr Singal I believe the issue at end is not the use of the PSA but the use of the PSA without context. Thanks for your support of me and your leadership on the issue Rajiv.

Posted: October 31, 2014

By: Tom Koor

1. The press reports seem to imply that PSA test results immediately lead to treatment - the step of the biopsy - which provides facts - has been left out of the discussion.
2. The "math" in the discussion seems suspect - i.e. reading that PSA testing only correlated with 1% improvement in mortality. But given that 80%+ persons do NOT have prostate cancer, this seems to imply 7-8% mortality improvement. And what about those with aggressive cancer - they have an even better chance of improvement due to PSA testing.
3. Most prostate cancer is slow progressing - seems to imply that could wait for symptoms to appear. What about the 2-3% with aggressive cancer - is it too late by the time symptoms appears?
4. Dr. Singal commented one time that the PSA test only provides some information - and some information is better than no information.
5. Keep up the great work Dr. Singal.

Posted: November 01, 2014

By: Joseph McCole

Hello All,

I found the task force comments confusing and those that spoke on their behalf on CBC anyway were not convincing. But I guess there is no smoke without fire and while I was living in Europe there were these rumblings. Little did I know that it would affect me then.

I was diagnosed a year ago, I am 56 now, based not on high numbers but family history and then accelerating numbers but still low. 70% cancer in the organ when removed. My dad and two older siblings were diagnosed at exactly the same age and in spite of completely different life styles and environments. I emigrated from Ireland at 26, my Dad did not smoke or drink.

Happy to have it removed.

I have a few questions/comments :

I need to be able to tell my three boys how to reduce their risk and the myths need to be sunk or proven with hard research:

Heard a great ted talk recently suggesting how emotional relationships can elevate or lower risk.

Some suggestions regarding vasectomies- Of my family members I was the only one to have the Vasectomy.

The fire hall cure for everything - lots of sex to keep the pipes clean - no smoke without fire and there was some wisdom shared in the fire stations where I worked.

Great show on Doc zone suggesting that there is a marinade that completely eliminates the threat to the Prostate from burned red meat.

What I really regret is that I did not donate my Prostate to science to see what it is about mine that made it so prone - Could it be a simply case of the shape, slope ets I was very prone to ear aches as a kid and apparently that can be the issue there. Or could the family gene be identified.

Hopefully by the time my boys are that age the treatment of Cell treatment under MRI wil be perfected.

Conclusion we need to hear more facts on how to prevent it and circulate to those of us with male children that could be vulnerable.

AND FOR GODS Sake please only do biopsies under anaesthetic. Both my brothers and I felt that that part of it needs to done with a little more dignity and care.

Thank you Dr SIngal for creating this opportunity to comment.

Regards
J

Posted: November 02, 2014

By: Terry Maloney

Rajiv - first of all - an extremely well written response. In my view , you are bang on !! And certainly, I'm a prime example of the value of the test as a lead indicator. I know reactions to biopsy's can be different for everyone but in my case it was pretty much a "non event". In any case , I really wonder why the worry of regarding biopsies as possible over treatment.

Posted: November 03, 2014

By: Dr. Michael Chang

As a practicing urologist, I feel very disappointed and powerless with the task force recommendations on PSA screening. I completely agree with Rajiv's position on this issue. PSA is not a number but a tool to understand the risk of prostate cancer. How were the members of the task force chosen? Why was there such a imbalance? What's the ultimate goal of such recommendations? to save lives? I don't think so. Only time will tell but these recommendations will create more harm than good. Metastatic disease will spread like fire and the cost to the health care system will be even greater. The worse part is that family physicians and nurse practitioners will follow these recommendations and ignore risk factors such as family history and ethnic background as well as forget about prostate examination. Correct me if I am wrong but a lot of family practitioners don't even know how to do proper prostate examination, which is also not being taught in medical school. Unfortunately, we will be in the dark and I am afraid it may be for a while. However, I will continue to ask "have you had a PSA test this year?"

Posted: November 10, 2014

By: Russ

Testing and more testing.

Posted: November 14, 2014

By: Peter K

The direction they're heading does seem to be an incredulous step backward. The irony of this and the "Movember" campaign happening around the same time is sad. Feels like we should be wearing a blindfold, not a mustache.

Posted: December 17, 2014

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