Prostate Cancer Test Recommendation

May 29, 2012

Transcript:

Ted Simons: THE U.S. PREVENTIVE SERVICES TASK FORCE RECENTLY ISSUED A RECOMMENDATION AGAINST SCREENING MEN OF ANY AGE FOR PROSTATE CANCER USING THE PSA BLOOD TEST. THE CONTROVERSIAL RECOMMENDATION HAS SHARPLY DIVIDED THE MEDICAL COMMUNITY. JOINING ME TO TALK ABOUT THE PSA TEST FOR PROSTATE CANCER SCREENING IS DR. MOE BELL, ASSOCIATE DIRECTOR OF SCOTTSDALE HEALTH CARE'S COMMUNITY HEALTH SERVICES, AND A SUPPORTER OF THE TASK FORCE RECOMMENDATION. AND DR. ERIK CASTLE, A UROLOGICAL SURGEON FOR THE MAYO CLINIC IN SCOTTSDALE. DR. CASTLE IS OPPOSED TO THE RECOMMENDATION. THANKS FOR JOINING US. WE APPRECIATE IT. LET'S START WITH SOME BASICS HERE. THE PSA TEST, WHAT IS IT? WHAT DOES IT DO?

Dr. Moe Bell: WELL, IT'S A SIMPLE BLOOD TEST THAT I WILL PROBABLY DEFER TO DR. CASTLE AS FAR AS THE BIOCHEMISTRY BUT IT'S A TEST THAT CAN HELP DIAGNOSE PROSTATE CANCER EARLY. BUT UNIVERSAL, IN MY OPINION, IT'S NOT A GOOD TEST BECAUSE THERE ARE MANY, MANY FALSE POSITIVE TESTS. MEN WHO HAVE AN ELEVATE THE BLOOD TEST WHO DO NOT HAVE PROSTATE CANCER, WHO HAVE BENIGN DISEASE.

Ted Simons: I DON'T WANT TO GET TO THOSE ARGUMENTS IN A SECOND HERE BUT AGAIN, THE TEST IS A SIMPLE BLOOD TEST ADMINISTERED AS A BLOOD TEST AND THEN LATER THE NUMBER COMES BACK, AND THE NUMBER FIT FALLS WITHIN A CERTAIN PARAMETERS, WHAT HAPPENS?

DR. ERIK CASTLE: WELL, THE TEST IS A PROTEIN THAT'S PRODUCED BY PROSTATE CELLS. ANYTHING THAT SIMULATES THE PROSTATE CELLS, IT CAME OUT IN THE LATE '80s WHEN IT WAS DETERMINED THIS WAS A WAY TO NOT ONLY FOLLOW PROSTATE CANCER OW TO SCREEN FOR IT. AND ANYTHING THAT CAN INFLAME THE PROSTATE WHICH IS, DR. BELL WAS POINTING OUT, EVEN SOMETIMES WHEN THERE ISN'T CANCER THE PSA TEST MAY BE ELEVATED. THAT'S WHAT CONCERNS SOME PEOPLE.

Ted Simons: CAN OTHER CONDITIONS LEAD TO THESE HIGHER LEVELS? CONDITIONS WAY OFF?

DR. ERIK CASTLE: ABSOLUTELY. BUT THE MOST COMMON ONES ARE AN ENLARGED PROSTATE BECAUSE THAT'S MAKES MORE PSA AND INFLAMMATION. AND THEN PROSTATE CANCER.

Ted Simons: OK. HOW OFTEN IS THIS A FALSE POSITIVE OR FALSE NEGATIVE.

Dr. Moe Bell: VERY COMMONLY. I WOULD SAY BY FAR THE MAJORITY OF THE TIME. MOST ELEVATED PSA TESTS ARE NOT DO YOU TO CANCER AND THE PROBLEM IS MANY MEN WITH CANCER DO NOT HAVE ELEVATED PSA TESTS. SO THE TEST IS NOT A GREAT TEST IN MY OPINION. BUT WHETHER TO USE IT FOR SCREENING WILL DEPEND ON OTHER THINGS SUCH AS DOES IT ULTIMATELY SAVE LIVES?

Ted Simons: INDEED, WITH THAT IN MIND, IF YOU TAKE THE TEST, AND 9 LEVELS ARE ELEVATED, WHAT'S NEXT? WHAT COULD YOU DO YOU DO?

DR. ERIK CASTLE: THE TERM FALSE POSITIVE HAS TO BE PUT IN PERSPECTIVE. WHEN YOU THINK OF A FALSE POSITIVE YOU ARE SAYING THE TEST IS SAYING ONE THING OR THE OTHER. WHAT THE TEST SAYS IS THAT YOU MIGHT HAVE PROSTATE CANCER. AND WHY THE USPS CALLS IT A FALSE POSITIVE BECAUSE THAT OFTEN LEADS TO A PROSTATE BY OPEN PEA. THAT'S A PROCEDURE THAT'S DONE IN THE OFFICE OF THE UROLOGIST WITHOUT GENERAL ANESTHESIA AND AN ULTRASOUND PROBE IS USED TO DIRECT BIOPSIES. WITH ANY OTHER CANCER MOST PEOPLE WOULD NOT TO KNOW IF THEY WANT CANCER. THE TEST DOESN'T SAY YES OR KNOW, IT LETS US KNOW, YES, WE NEED TO INVESTIGATE FURTHER. THAT'S THE ELEVATED TEST ALLOWS US TO DO.

Ted Simons: SOUNDS LIKE MORE INFORMATION. WHY WOULD MORE INFORMATION NOT NECESSARILY BE A GOOD THING?

Dr. Moe Bell: EVERY CANCER IS DIFFERENT. AND PROSTATE CANCER NOTORIOUSLY MANY MEN LIVE LONG, LONG PERIODS OF TIME WITH SLOW GROWING PROSTATE CANCERS. IN FACT, IF YOU LIVE TO BE 85, MORE THAN HALF OF ALL MEN ACTUALLY HAVE PROSTATE CANCER ON AUTOPSY IF THEY DIE OF SOMETHING ELSE. SO MORE THAN HALF. BUT THE VAST MAJORITY OF THOSE MEN DON'T DIE OF PROSTATE CANCER. A VERY, VERY MALL, SOMETHING LIKE 3% OF MEN ULTIMATELY DIE OF PROSTATE CANCER. SO IF YOU WERE AN OLDER GENTLEMAN, AND HAVE PROSTATE CANCER, AND IT'S NEVER GOING TO BOTHER YOU, MY FEELING IS, WHY YOU WANT TO KNOW ABOUT IT? WHY WOULD YOU WANT TO GO THROUGH THE INVASIVE TESTS? THE TREATMENT, BECAUSE ONCE YOU HAVE IT, PSYCHOLOGICALLY, MOST MEN IN AMERICA AREN'T GOING TO SAY, O. IT'S SLOW GROWING, I'M GOING TO WAIT AND WATCH.

DR. ERIK CASTLE: IT NEEDS TO BE PUT IN PERSPECTIVE. THE PANEL IS A GROUP OF PEOPLE PUT TOGETHER BY THE DEPARTMENT OF HEALTH AND HUMAN SERVICES, IT WAS TO DETERMINE WHETHER IT WAS USEFUL. THE THING THAT'S BEEN MISSED WITH THIS WHOLE ANALYSIS IS, THEY ONLY FOCUSED ON YOU THINK 1 THING WHICH WAS DEATH FROM DISEASE. UROLOGISTS, ONCOLOGISTS, BY THE WAY NONE OF WHICH WERE ON THIS PANEL. THIS PANEL WAS COMPRISED OF PEDIATRICIAN, STATISTICIANS AND ESSENTIALLY NO ONE THAT TREATS PROSTATE CANCER OR HAS SEEN A PATIENT DIE FROM PROSTATE CANCER. BUT THE POINT IS THAT WE DON'T ALWAYS JUST TRY TO EXTEND LIFE. WE ARE ALSO TRYING TO IMPROVE QUALITY OF LIFE. AND THEY ONLY FOCUSED ON THE INCONVENIENCE OF A BIOPSY WHICH I ALWAYS TELL MY MALE PATIENTS THINK OF ALL THE UNCOMFORTABLE EXAMS FEMALE PATIENTS AND THEIR LIVES HAVE UNDERGONE BY GYNECOLOGISTS AND YOU HAVE TO DO ONE RECTAL EXAM AND THEY BECOME VERY UNCOMFORTABLE.

Dr. Moe Bell: I HAVE TO RESPECTFULLY DISAGREE WITH DR. CASTLE IN A COUPLE OF AREAS. FIRST OFF THE U.S. PREVENTATIVE SERVICES TASK FORCE HAS INDIVIDUALS FROM MANY SPECIALTIES MANY OF WHOM HAVE HAD PERSONAL PATIENTS WHO DIED FROM PROSTATE CANCER. I HAVE A FRIEND ON THE PANEL WHO HAD MANY PATIENTS GO THROUGH THAT TERRIBLE EXPERIENCE. AND A RECTAL BIOPSY IS NOT A BENIGN PROCESS. THERE'S AN ULTRASOUND PROBE PLACED IN THE RECTUM. 10 OR AS MANY AS 18 THICK NEEDLE CORES ARE REMOVED FROM THE PROSTATE. THERE'S MORE AWARENESS OF INFECTIONS THAT OCCUR AFTER BIOPSIES. MEN GET HOSPITALIZED ON OCCASION. THAT'S NOT A BENIGN PROCEDURE WHEN YOU CONSIDER THAT, WITH IF YOU SCREEN ALL MEN, I THINK PROBABLY HALF OR MORE ARE GOING TO END UP AT SOME POINT GETTING A BIOPSY.

DR. ERIK CASTLE: WELL, THE STANCE OF THE AMERICAN UROLOGIC ASSOCIATION IS THAT MORE INFORMATION AS YOU PUT, TED, IS BETTER FOR A PATIENT. I THINK THE CONCERN THAT WE HAVE WITH THE CURRENT RECOMMENDATION, WHICH IS WHAT'S CALLED A GRADE D RECOMMENDATION. SO THE USPTF DIDN'T JUST SAY IT'S UP TO THE PATIENT AND PHYSICIAN TO DETERMINE WHETHER THEY WANT TO DETERMINE WITH FURTHER TESTING. THEY SAID, WE ARE AGAINST PROSTATE CANCER SCREENING IN ALL PATIENTS REGARDLESS OF AGE. SO THAT EVEN INCLUDES PATIENTS THAT SIGNIFICANT RISK FOR DEATH FROM DISEASE SUCH AS AFRICAN AMERICANS AND PEOPLE WITH FAMILY HISTORY. WE FEEL, UROLOGISTS, ONCOLOGISTS, THOSE OF US THAT TREAT AND PERFORM THE BIOPSIES AND DO THESE PROCEDURES AND FOLLOW THESE PATIENTS, FEEL THAT IT'S THE RESPONSIBILITY OF THE PHYSICIAN AND THE PATIENT TO COME TOGETHER AS A TEAM TO DETERMINE WHAT THEY WANT TO DO WITH THAT INFORMATION.

Ted Simons: AGAIN, THE QUESTION, HOW CAN EARLY DETECTION, A HINT OF EARLY DETECTION, THE SUGGESTION OF EARLY DETECTION, I THINK FOR A LOT OF MEN WATCHING THIS AND CERTAINLY THIS DEBATE HAS BEEN GOING ON, HOW CAN THAT NOT BE A GOOD THING?

Dr. Moe Bell: HERE'S WHY. THERE'S SIGNIFICANT, SIGNIFICANT HARMS ASSOCIATED WITH IT. AND THE TWO KEY TRIALS CAME OUT A COUPLE YEARS AGO. THE ONE IN THE UNITED STATES FOUND, AGAIN, NO BENEFIT AS FAR AS YOU SCREEN A BUNCH MEN. IT WASN'T A PERFECT STUDY.

DR. ERIK CASTLE: A VERY FLAWED STUDY.

Dr. Moe Bell: IT WASN'T A PERFECT STUDY. THEY FOUND AFTER I THINK 10, 11 YEARS THERE WAS ABSOLUTELY NO DIFFERENCE IN DEATH RATES FROM PROSTATE CANCER WHETHER YOU SCREENED MEN OR NOT. A EUROPEAN STUDY DID FIND A SLIGHT BENEFIT THAT ROUGHLY, I THINK THE NUMBERS WERE, IF YOU SCREENED 1400 MEN, YOU MIGHT SAVE ONE LIFE. WHICH MIGHT BE A GOOD THING TO DO EXCEPT THEY ALSO FOUND, YOU WOULD HAVE TO TREAT 48 MEN, YOU WOULD HAVE TO DIAGNOSE THEM WITH PROSTATE CANCER, TREAT 48 OF THEM, RESULTING IN SIGNIFICANT SIDE EFFECTS SUCH AS ERECTILE DYSFUNCTION --

Ted Simons: YOU KNOW WHAT'S INTERESTING, THIS IS THE ONLY CANCER THAT WHEN WE TALK ABOUT OUTCOMES, SURVIVING THE CANCER, SUFFERING FROM THE CANCER ITSELF, WE COMPARE IT TO WHETHER SOMEONE IS GOING TO HAVE TO WEAR A SECURITY DIAPER IN THEIR UNDERWEAR OR WHETHER THEY ARE GOING TO BE ABLE TO HAVE INTERCOURSE. AND ANY OTHER CANCER, LET'S TAKE PANCREATIC CANCER, FOR EXAMPLE, THAT'S VERY POPULAR AND ON THE MINDS OF A LOT OF PEOPLE BECAUSE WE HAVE SEEN CELEBRITIES DIE FROM IT. A DISEASE THAT HAS A 5 TO 10% FIVE-YEAR SURVIVAL RATE AND PROSTATE CANCER IN THE PREPSA ERA HAD A APPROXIMATELY 50% SURVIVAL RATE. 50% OF PATIENTS DIED WITH DIE. TODAY THE FIVE-YEAR SURVIVAL RATE FOR PROSTATE CANCER IS WELL OVER 98%.

Ted Simons: HOW DO YOU EXPLAIN THOSE NUMBERS.

Dr. Moe Bell: IT'S VERY MISLEADING. BEFORE WE HAD A PSA, MEN WERE DIAGNOSED MUCH SMALLER NUMBER OF MEN WERE DIAGNOSED, AND THOSE HAD SEVERE DISEASE AND THEY WERE DIAGNOSED NEAR THE END OF THEIR LIFE. WITH PSA SCREENING, YOU CAN FIND MEN WHO ARE DESTINED TO LIVE 20, 25 YEARS WITHOUT THE CANCER EVER HURTING THEM. YOU FIND IT SO EARLY THAT MANY, MOST OF THEM, BY FAR WE KNOW THE MAJORITY OF THOSE MEN, WILL DIE OF OTHER THINGS HAPPILY NEVER KNOW THEY HAD PROSTATE CANCER. THEY WILL DIE OF A HEART ATTACK ARE A STROKE. THEY WILL BE IGNORANT OF IT AND HAPPILY IGNORANT BECAUSE THEY DIDN'T GO THROUGH ALL THAT TREATMENT.

Ted Simons: IT SOUNDS TO ME WHAT I AM HEARING FROM YOU IS THAT THIS IS CANCER, AND CANCER CONJURES UP CERTAIN IMAGES, BUT THIS IS NOT THE KIND OF CANCER WE THINK OF WHEN WE USUALLY THINK OF THAT PARTICULAR DISEASE. YOU ARE SAYING, YOU ARE SAYING THAT FOR THE MOST PART, PEOPLE CAN LIVE WITH THIS FOR DECADES?

Dr. Moe Bell: WELL, THERE'S A RANGE. NOW, HERE'S THE OTHER SAD PART. THERE ARE VERY AGGRESSIVE PROSTATE CANCERS. BUT EVEN WITH UNIVERSAL SCREENING, EVEN IN THE BEST OF HANDS, WE MAY SAVE -- YOU SCREEN 1,000 MEN, YOU MIGHT SAVE ONE LIFE, BUT FOUR OR FIVE MEN ARE GOING TO DIE OF PROSTATE CANCER ANYWAY. AND THAT'S BECAUSE THEY ARE UNFORTUNATE ENOUGH TO GET AN AGGRESSIVE FORM THAT THE CURRENT TREATMENTS JUST DON'T WORK WELL FOR.

DR. ERIK CASTLE: SO THERE'S ABSOLUTELY NO DOUBT THAT THERE'S A LARGE PERCENTAGE OF PATIENTS THAT ARE DIAGNOSED WITH PROSTATE CANCER THAT MAY NOT DIE FROM THEIR DISEASE. BUT THE PROBLEM WITH GOING AGAINST UNIVERSAL SCREENING, TO GO AGAINST THE ONLY BLOOD TEST THAT'S AVAILABLE TO SCREEN FOR A CANCER, PERIOD, AHEAD OF TIME, NOT JUST FOLLOWING BUT IDENTIFYING IT, IS SURPRISING. BECAUSE RIGHT NOW, IN THE UNITED STATES, THE SECOND MOST COMMON CAUSE OF CANCER DEATH IN MEN IS PROSTATE CANCER. SO MORE MEN DIE FROM PROSTATE CANCER EVERY SINGLE YEAR THAN COLON CANCER, THAN BRAIN CANCER, PANCREATIC CANCER. WHAT WE NEED TO DO IS DO A BETTER JOB OF KNOWING HOW TO PROCESS THE INFORMATION. GIVE PATIENTS THAT OPPORTUNITY TO MAKE THAT DECISION.

Ted Simons: THAT'S A GOOD QUESTION. WHY NOT GO AHEAD AND FIND A BETTER TEST BEFORE -- BEFORE DITCHING THIS ONE?

DR. ERIK CASTLE: ABSOLUTELY.

Dr. Moe Bell: I THINK WE NEED BETTER TESTS. AND I THINK WE ARE WORKING ON IT. I THINK WE DON'T KNOW HOW TO USE THIS TEST QUITE HONESTLY. THERE ARE MANY DIFFERENT STRATEGIES AND CUTOFF POINTS. IF YOUR PSA IS GREATER THAN FOUR YOU GET BIOPSIED. IF IT'S GREATER THAN 3, IT'S JUST NOT A VERY GOOD TEST. MEANWHILE, WHAT THE TASK FORCE FOUND, THERE WAS SIGNIFICANT HARMS ASSOCIATED WITH OVERDIAGNOSE AND OVERTREATMENT.

DR. ERIK CASTLE: IT'S AN -- THE TASK FORCE, UNFORTUNATELY, THE DOWN SIDE TO THE TASK FORCE WASN'T THAT THEY WERE DOING THIS ANALYSIS. IT'S THE WAY THEY DID THEIR ANALYSIS. THERE WASN'T ANY CLINICAL PERSPECTIVE IN THE ANALYSIS. FOR EXAMPLE, IN THE STUDIES THAT THEY QUOTE, THE PLCO TRIAL THAT DR. BELL IS REFERRING TO, WHEN THEY COMPARED THE TWO GROUPS, 52% OF THE GROUP THAT THEY WERE USING AS THE NONSCREEN GROUP ACTUALLY WERE SCREENED FOR PROSTATE CANCER. 2/3 GOING INTO THE STUDY HAD BEEN SCREENED. SO ANYBODY WHO UNDERSTANDS SCREENING STUDIES WOULD KNOW THAT THAT STUDY WAS FAILED.

Ted Simons: BUT BACK TO AN EARLIER POINT. THE PSYCHOLOGICAL IMPACT OF BEING TOLD, YOUR NUMBERS ARE UP, YOU COULD VERY WELL HAVE PROSTATE CANCER WHEN, IN REALITY, YOU COULD VERY WELL HAVE A PROSTATE CANCER THAT EITHER NEVER SPREADS OR SPREADS SO SLOWLY THAT YOU COULD BE IN 110 YEARS OLD AND STILL THAT SAME LEVEL ON THE PSA TEST. PSYCHOLOGICAL IMPACT DOES HAVE TO COME INTO PLAY, DOESN'T IT?

DR. ERIK CASTLE: IT ABSOLUTELY DOES. THAT'S THE RESPONSIBILITY OF THE PHYSICIAN OR THE HEALTH CARE PROVIDER TO WORK WITH THE PATIENT. AND I THINK THAT'S WHAT'S BEEN LOST IS WHEN THE USPFTF COMES OUT WITH A RECOMMENDATION TO BASICALLY TAKE THAT OUT OF THE HANDS OF THE PHYSICIAN AND THE PATIENT, TO USE THAT INFORMATION TO WORK THROUGH THAT PSYCHOLOGICAL IMPACT, AND DON'T FORGET THERE ARE A LOT OF PATIENTS WHO HAVE AN ELEVATED PSA, GET A BIOPSY THAT'S NEGATIVE AND FEEL VERY GOOD ABOUT THE FACT THEY DON'T HAVE CANCER. AND THAT WOULDN'T BE A FALSE POSITIVE IN MY MIND. IN MY MIND THAT'S FULLY A VERY POSITIVE FINDING FOR THE PATIENT.

Ted Simons: WHAT DO YOU MAKE OF THAT?

Dr. Moe Bell: WELL IF YOU INCLUDE THE PSA TESTING IS USELESS YOU HAVE A WHOLE BUNCH OF THOSE MEN WHO GOT EXTREMELY WORD, HAD AN INVASIVE BIOPSY, POTENTIAL FOR INFECTION, POTENTIAL FOR HOSPITALIZATION AND DOES IT THEM NO GOOD BECAUSE DID IT THEM NO BENEFIT. BUT WHAT I THINK WE COULD ALSO COMMENT, THOUGH, ON, THE TASK FORCE HAS LOOKED AT MANY OTHER, WHAT THEY TRY TO DO IS LOOK AT, THERE'S HUNDREDS AND THOUSANDS OF TESTS POTENTIALLY THAT A HEALTHY PERSON COULD COME IN TO A FAMILY PHYSICIAN OR INTERN CYST AND SAY, HEY, I FEEL GREAT. I'M HEALTHY BUT I WANT TESTS DONE. WE HAVE TO RATIONALLY CHOOSE WHICH TESTS SHOULD WE DO? AND THERE IS, THERE ARE SOME OF THAT WE REALLY SHOULD DO. AND THIS ONE, THEY'RE CONCLUDING FOR ROUTINE AVERAGE RISK.

Ted Simons: VERY QUICKLY, FINAL WORD.

DR. ERIK CASTLE: YEAH. THE AMERICAN UROLOGIC ASSOCIATION WOULD SAY THAT WHICH WE CAN'T FIND WE CANNOT TREAT. AND WE FEEL THAT NOT DOING THE TESTING IS LIKE PUTTING OUR HEAD IN THE SANDS.

Ted Simons: WE GOT TO STOP IT RIGHT THERE. GREAT CONVERSATION. GOOD TO HAVE YOU BOTH HERE. REALLY APPRECIATE IT.

DR. ERIK CASTLE: THANK YOU, TED.