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Re: Prostate cancer screening with prostate-specific antigen (PSA) test: a clinical practice guideline
Earlier this year I was most perplexed by some of the NHS campaigns to promote cancer awareness and left fearful that they may have caused more harm than good.
They do appear to be, on occasions, ill designed.
For instance, at that time I was literally inundated by PSA requests following a most recent prostate cancer campaign.
In the well-known advertisement at that time there was no mention whatsoever about age target, for instance.
To note that, not in the UK, where the test is free under the NHS scheme, I came across ads promoting its request, at a "fee", to "exclude" prostate cancer.
Some of the readers may recall a similar campaign about lung cancer inviting the general population, once again without any mention of age and smoking habits, to be checked by their own GP for a cough lasting more than 3 weeks as this could have been an indicator of cancer.
In both cases, most patients I have seen in response to the campaigns were below 40 years of age and in some occasions in their early 20s, often non-smokers. In fact, following the campaign about lung cancer, I do not recall having seen any heavy smoker with subacute or chronic cough coming to see me in response to the advertisement.
First of all, I think it should be stressed that cancer markers should never ever been used alone to diagnose cancer in asymptomatic patients or be presented misleadingly as such.
The case of the PSA suggests that it would be in the NHS interest promoting courses for GPs - and not only - about tumour markers and their use in clinical practice.
Around that time I received an invitation from the Italian Ministry of Health to take an online distance course on the topic - FREE.
It is a must, yet it rewards you with CME points for 10 hours of study. No points if you do not pass.
There are questions and the questions do change. So, if you get it wrong, I am afraid, you have got to do it all over again.
Few “souls” would argue that this type of course would not be helpful to NHS GPs and Consultants considering how often markers have been used in a not purely orthodox way.
I am sure the NHS would ultimately save money and that it would be beneficial to the patients (overdiagnosis and not just).
Unfortunately, practising in the NHS appears to be an “atypical” business and it is far easier to find “free courses” indirectly promoting some “new prescription”, or “procedure”, than an educational activity that could improve care and cut costs.
With specific reference to the PSA, Australian PSA testing guidelines also recommend that fully informed testing should commence at 45 years of age only for men with a family history of prostate cancer.
But the story is more complicated than that so much so that no one, anywhere in the World, has put in place automatic screening procedure for prostate cancer as it has been done for cervical, breast, and colonic cancer.
And this is the case for valid reasons.
What we know is that most men with an elevated PSA will proceed to biopsy. About one in four prostate biopsies will find prostate cancer, while the risk of significant bleeding or infection is 1% to 4% of patients. For those diagnosed with prostate cancer, approximately 90% will elect to have some sort of intervention. This includes surgery, radiation therapy, or androgen deprivation. All of these treatments may be associated with adverse effects, such as urinary, bowel and erectile dysfunction. Many patients may consider the adverse effects to be acceptable trade-offs for a procedure they regard as “lifesaving”. There is also the argument, that any morbidity associated with intervention, is better than the morbidity from metastasised prostate cancer.
That being said, a large study published in the NEJM in late 2016 showed how the comparative effectiveness of treatments for prostate cancer that is detected by prostate-specific antigen (PSA) testing remains uncertain. At a median of 10 years, prostate-cancer–specific mortality was low irrespective of the treatment assigned, with no significant difference among treatments.
It gets worse than that.
It has been argued that up to 50% of the prostate cancers detected would not have caused illness in the man’s lifetime. Therefore, for 50% of men any adverse effects from any intervention can be considered a harm.
Another, and perhaps even more grave downside of poorly designed awareness campaign is forgetting the impact they may have on the services.
In fact, among the rather young and asymptomatic patients suddenly bringing to their GP's attention following a campaign failing to highlight a more specific target, there will be false positives, which at that point would have to be referred to Secondary Care which will have not increased its capacity just to deal with the temporary surge in demand. Accordingly, this will delay the diagnosis for those with cancer indeed.
Diagnostic errors may be more likely, and this should not come very much as a surprise.
In fact, let us think about the surge in x-ray requests following the campaign for lung cancer which brought to GP attention young worried well non-smokers coughing for 3 weeks.
Besides the risk of over-diagnosis, the sudden raise in the number of films to look at may well increase the risk of misdiagnosis and missed diagnosis.
It is time to invest in designing specific guidelines for prostate cancer screening and even more to invest in research about the behaviour of prostate cancer.
As we are finding to be the case in many tumours, we may be calling the entities the same that are as similar as apples and pears and which should be tackled in different ways in view of their biological differences and indeed differences in the hosts.
Speaking of cancer awareness campaigns, I appreciated the similar most recent campaign about obesity as a potential cause of cancer, but no patient attended because of that one.
Saying "you may have cancer" clearly is more of a powerful message than "you may develop cancer”.
I remain of the opinion that, in Primary Care, prevention is better and cheaper than cure 10 times out of 10.
Your paper "Prostate cancer screening with prostate-specific antigen (PSA) test: a clinical practice guideline" does not solve the dilemma of how to respond to conflicting information, but highlights how pressing the issue is.
Rapid Response:
Re: Prostate cancer screening with prostate-specific antigen (PSA) test: a clinical practice guideline
Earlier this year I was most perplexed by some of the NHS campaigns to promote cancer awareness and left fearful that they may have caused more harm than good.
They do appear to be, on occasions, ill designed.
For instance, at that time I was literally inundated by PSA requests following a most recent prostate cancer campaign.
In the well-known advertisement at that time there was no mention whatsoever about age target, for instance.
To note that, not in the UK, where the test is free under the NHS scheme, I came across ads promoting its request, at a "fee", to "exclude" prostate cancer.
Some of the readers may recall a similar campaign about lung cancer inviting the general population, once again without any mention of age and smoking habits, to be checked by their own GP for a cough lasting more than 3 weeks as this could have been an indicator of cancer.
In both cases, most patients I have seen in response to the campaigns were below 40 years of age and in some occasions in their early 20s, often non-smokers. In fact, following the campaign about lung cancer, I do not recall having seen any heavy smoker with subacute or chronic cough coming to see me in response to the advertisement.
First of all, I think it should be stressed that cancer markers should never ever been used alone to diagnose cancer in asymptomatic patients or be presented misleadingly as such.
The case of the PSA suggests that it would be in the NHS interest promoting courses for GPs - and not only - about tumour markers and their use in clinical practice.
Around that time I received an invitation from the Italian Ministry of Health to take an online distance course on the topic - FREE.
It is a must, yet it rewards you with CME points for 10 hours of study. No points if you do not pass.
There are questions and the questions do change. So, if you get it wrong, I am afraid, you have got to do it all over again.
Few “souls” would argue that this type of course would not be helpful to NHS GPs and Consultants considering how often markers have been used in a not purely orthodox way.
I am sure the NHS would ultimately save money and that it would be beneficial to the patients (overdiagnosis and not just).
Unfortunately, practising in the NHS appears to be an “atypical” business and it is far easier to find “free courses” indirectly promoting some “new prescription”, or “procedure”, than an educational activity that could improve care and cut costs.
With specific reference to the PSA, Australian PSA testing guidelines also recommend that fully informed testing should commence at 45 years of age only for men with a family history of prostate cancer.
But the story is more complicated than that so much so that no one, anywhere in the World, has put in place automatic screening procedure for prostate cancer as it has been done for cervical, breast, and colonic cancer.
And this is the case for valid reasons.
What we know is that most men with an elevated PSA will proceed to biopsy. About one in four prostate biopsies will find prostate cancer, while the risk of significant bleeding or infection is 1% to 4% of patients. For those diagnosed with prostate cancer, approximately 90% will elect to have some sort of intervention. This includes surgery, radiation therapy, or androgen deprivation. All of these treatments may be associated with adverse effects, such as urinary, bowel and erectile dysfunction. Many patients may consider the adverse effects to be acceptable trade-offs for a procedure they regard as “lifesaving”. There is also the argument, that any morbidity associated with intervention, is better than the morbidity from metastasised prostate cancer.
That being said, a large study published in the NEJM in late 2016 showed how the comparative effectiveness of treatments for prostate cancer that is detected by prostate-specific antigen (PSA) testing remains uncertain. At a median of 10 years, prostate-cancer–specific mortality was low irrespective of the treatment assigned, with no significant difference among treatments.
It gets worse than that.
It has been argued that up to 50% of the prostate cancers detected would not have caused illness in the man’s lifetime. Therefore, for 50% of men any adverse effects from any intervention can be considered a harm.
Another, and perhaps even more grave downside of poorly designed awareness campaign is forgetting the impact they may have on the services.
In fact, among the rather young and asymptomatic patients suddenly bringing to their GP's attention following a campaign failing to highlight a more specific target, there will be false positives, which at that point would have to be referred to Secondary Care which will have not increased its capacity just to deal with the temporary surge in demand. Accordingly, this will delay the diagnosis for those with cancer indeed.
Diagnostic errors may be more likely, and this should not come very much as a surprise.
In fact, let us think about the surge in x-ray requests following the campaign for lung cancer which brought to GP attention young worried well non-smokers coughing for 3 weeks.
Besides the risk of over-diagnosis, the sudden raise in the number of films to look at may well increase the risk of misdiagnosis and missed diagnosis.
It is time to invest in designing specific guidelines for prostate cancer screening and even more to invest in research about the behaviour of prostate cancer.
As we are finding to be the case in many tumours, we may be calling the entities the same that are as similar as apples and pears and which should be tackled in different ways in view of their biological differences and indeed differences in the hosts.
Speaking of cancer awareness campaigns, I appreciated the similar most recent campaign about obesity as a potential cause of cancer, but no patient attended because of that one.
Saying "you may have cancer" clearly is more of a powerful message than "you may develop cancer”.
I remain of the opinion that, in Primary Care, prevention is better and cheaper than cure 10 times out of 10.
Your paper "Prostate cancer screening with prostate-specific antigen (PSA) test: a clinical practice guideline" does not solve the dilemma of how to respond to conflicting information, but highlights how pressing the issue is.
Competing interests: No competing interests