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Before PSA Screening, 'People Were Drowning'


May 29, 2012 (Atlanta, Georgia) — Urologists were up in arms over the new guidelines against prostate-specific antigen (PSA) screening here at the American Urological Association (AUA) 2012 Annual Scientific Meeting, and pointed out they have different perspectives than primary care physicians.
Many older urologists remember a time when they regularly saw men with advanced prostate cancer at their first urology consult.
"It was as if people were drowning all around us," said Ian Thompson, MD, director of the Cancer Therapy & Research Center at the University of Texas Health Science Center at San Antonio, and chair of the AUA prostate cancer guideline panel. When the PSA test came along in the 1980s, urologists saw it as a life preserver that could save patients' lives by detecting prostate cancer at an earlier stage, he said.
That might explain why emotions ran so high at the annual meeting, which coincided with the release of the federal guideline recommending against routine PSA tests for men of any age. The final guideline from the United States Preventive Services Task Force (USPSTF) recommends against routine PSA screening; it concludes that there is moderate certainty that the benefits do not outweigh the harms.
Entering the Lion's Den
"Telling us to 'cease and desist' from offering PSA tests is just callous," said William Catalona, MD, professor of urology at the Feinberg School of Medicine, Northwestern University, in Chicago, Illinois. In a debate that drew a standing-room-only crowd, Dr. Catalona went head to head with one of the guideline authors, Timothy Wilt, MD, MPH. The moderator of the debate thanked Dr. Wilt for "entering the lion's den" to represent the views of the USPSTF.
Some attendees walked out of the confrontational session, one describing it as "polarizing nonsense." But many of Dr. Catalona's most strident attacks were met with cheers and applause from the urologist audience.
The role of the USPSTF, Dr. Wilt explained, is to evaluate the benefits and risks of preventive health tools. "The task force does not recommend screening tests where the benefits do not outweigh the harms," he said.
Although Dr. Wilt repeated that mantra several times, the actual wording of the latest report is considerably stronger than that, concluding that "there is moderate or high certainty...that the harms outweigh the benefits."
The decision to go beyond "not recommending" the test to "recommending against" it particularly rankled many urologists, including the leadership of the AUA. The organization issued a formal response, expressing its "outrage" at the guidance.
"Rather than instructing primary care physicians to discourage men from having a PSA test, the task force should instead focus on how best to educate primary care physicians regarding targeted screening and how to counsel patients about their prostate cancer risk," the statement said.
Fritz Schröder, MD, international coordinator of the European Randomized Study of Screening for Prostate Cancer, also took issue with the new guideline. In an earlier session, where both he and Dr. Wilt served on a panel, he said he is concerned about the data used by the task force to reach its conclusions, specifically meta-analyses that he said include "problematic" studies.
Dr. Wilt defended the analysis, saying it was based primarily on 2 large trials, one of which Dr. Schröder oversaw himself. "Our recommendations did not and do not include meta-analyses," he stated.
Later, at the open debate session, Dr. Schröder took to the microphone to confront Dr. Wilt about the task force's work.
One of the main arguments against routine PSA screening is that it leads to overdiagnosis and overtreatment. It can pick up prostate cancer that is so slow growing that it would never interfere with a man's quality of life, yet finding it sets him on a path of treatment that could cause harm.
"Why didn't you look at ways to decrease overdiagnosis and overtreatment?" he asked Dr. Wilt. "If there is a way out of this, I think it is up to the task force to point the way."
 

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