In another thread someone stated:
"probably have the same effect as not PSA testing young guys like Tony C ironically used to push on this forum a few years ago. we can now see how that worked out."
Since I know I was targeted with what I feel is a opinionated distortion (at best), there's some clarifications I think I'm entitled to make here. 1st I have never "pushed" to have no PSA screening in younger men at anytime here or anywhere. I was after all a 44yo that was diagnosed as advanced in 2006. I was not screened for prostate cancer per se because the "guideline" at the time stated to start testing men at age 50. 45 if African American or with family history. So I was outside all screening protocol at the time which I found frustrating. I vehemently sounded that alarm here at HW. Instead another medical condition was present that led to a diagnostic PSA test in my case that came back at 20ng/dl and began my journey.
My PSA viewpoint history:
Milestone 1: In 2009 the United States Preventive Services Task Force issued a Grade D recommendation to end all PSA screening in all men in the US regardless of age, family history, or race. Reviewing my posting here at the time will reveal that I was the first one to post about
it and raise the flag of protest about
it. This recommendation was based upon the review of two 2008 New England Journal of Medicine studies - the PLCO screening review in North America, and the ERSPC meta-analysis done in Europe. I was also the first to post those documents here as I was beginning to develop contacts in prostate cancer and Dr. Gerry Chodak (RIP) shared them with me before they were published. The USPSTF recommendation went through (Wilt, et al) and a lot of controversy followed. The recommendation was also silent on the use of a DRE.
Milestone 2: In 2010, the American Urological Associate (AUA) banded a panel together to review Wilt, et al, and to provide a counter research on screening. This was when I attended my first AUA conference in San Francisco and attended a presentation that found:
1. The USPSTF used a flawed study in the PLCO that determined there was no survival benefit to screening for prostate cancer
2. The USPSTF incorrectly used the data from the ERSPC document which stated that you would need to screen 1000 men and treat 43 in order to save a single life and that would also result in no benefit due to mortality caused by treatment and morbidities which were rampant at the time experienced by men treated with prostate cancer.
3. There was no oncology representation on the USPSTF panel and no experience treating prostate cancer was used.
Milestone 3: in 2013 the AUA panel issued a guideline on Early Detection of Prostate cancer. https://www.auanet.org/guidelines/prostate-cancer-early-detection-guideline
The reason for the guideline was to refine issues in screening and to counter the USPSTF findings. Additionally, the AUA community as well as the ASTRO community, needed an expert panel to draft guidelines in help prevent legal and financial situations that were arising from the USPSTF. The methodology in creating this guideline reviewed over 800 studies and 115 were originally cited. (Later updated to 121). It was this document and my support of it that led to some here flipping out and creating a hostile environment for me here to resign as a moderator particularly with a few that absolutely were not willing to accept this and hold it against me leading to me leaving the site entirely for a while. In this guideline are 5 statements. The document is drafted to those that would be primary doing the screening as well as others in the PCa community including patients. The first 2 statements talk about
screening younger men. They recommend against screening below age 40, and not routinely screening men between age 40 and 54. If you take the time to read the document they do not eliminate either as de facto rules. This was with the intention of providing guidelines using the available studies and science.
Milestone 4: The USPSTF, citing the AUA guideline, and updated data from the ERSPC, lifted the grade D halt to all screening. That was what I was hoping for but it did so conditionally. They only applied a Grade A to statement 3, and they did not adopt any of the other recommendations.
Milestone 5: in 2017, the AUA/ASCO/ASTRO/SUO reviewed this document again and reassembled a panel to tweak or modify it. This is the first time a patient representative was added to the panel. I was that patient representative and served on that review. In addition to reviewing the existing citations, we reviewed 77 additional screening studies. We found no data available to change the original guideline based on any science. So in 2018 we re-released the documents adding notations and 6 more citations. I spoke to and worked with the original panel raising concerns I heard here and other websites after the original release. Ball Carter brought up some points that we didn't get to hear in 2013. Namely:
1. Statement 1 was created because there was precisely no data on where and how PSA should be used in patients and that the primary care physicians that would be the likely do this screening, had very little information to use on PSA levels in a man in his 30's. The standard at the time for PSA screening was that if the PSA was below 4.0 everything was fine. We know very little still today about
PSA kinetics in men in their 30's or even early 40's. But we know that using a hardline of 4.0 is absolutely mistaken in any men in the screening process regardless of age.
2. Statement 2 is the very first recommendation that allow any form of prostate cancer screening in men below the age of 45. I caught that right from the get go. I made that point to several deaf ears online.
3. The guideline clearly stated in 2013 and in the review that these are recommendations based upon cohort and not individuals. It clearly states that if a patient insists on PSA tests and the SDM requirements were met, they should be tested regardless of age or history.
4. We are still early in the study of molecular biomarkers but Carter felt then that as we can tie more high risk cases to genetic signatures in patients where a father or mother had prior cancer incidence that it could drive earlier testing in men. He also felt that new strategies will become available if and when we develop better screening biomarkers such as circulating tumor DNA (ctDNA) and biopsy (liquid biopsy).
Milestone 6: Published more recently are studies that outline that we are seeing an increase in high risk, advanced, or even mortality and some place the blame on changes in screening. More in depth look tells us there are several factors that have done this. An ASCO panel was assembled and found:
1. While more advanced cases are showing at presentation, overall survival was largely unchanged due to when a patient was screened.
2. The population is clearly heavier and has more co-morbidities than prior to 2005 screening guidelines when the controversy arose.
In 2005 the American Cancer Society's medical director, Dr. Otis Brawley, was adamantly against prostate cancer screening. Especially in African American men. I have met him at a plenary for SWOG and I asked him while he was on stage if he still held that position. To the gasps of the entire oncology group, he went on a rage about
it citing racism and a medical community that was taking advantage and mistreatment of African Americans. Important note: Dr. Brawley is an African American. After the plenary I went up to Brawley and told him I disagree with him but I did admire his convictions. He stuck to his guns even though in my option he was contributing to what we find today in a drop in screening. he basically said "Good."
[edited here - per ASAdvocate] Last note: And many probably won't like this one. As an advocate that supports active surveillance, I fully acknowledge that after PSA screening changes, AS is the leading cause of increase in stage shifting in prostate cancer perhaps combined with the lack of science to improve screening. There are no perfect answers and no clear studies based upon prospective data on why this is. And it's not obvious either. To improve screening we need the following:
1. Education. Men need to understand that they can request screening regardless of age. But that guidelines are done to prevent abuse, misuse, and unnecessary treatment or diagnosis.
2. PSA alone is still a terrible screening tool. It's not prostate cancer specific and it leads to anxiety and even depression in patients who get "false positive" readings.
3. We need better biomarkers and radiographic imaging (these are coming).
4. We need less invasive tools for screening and biopsy.
I hope this explains more accurately than the above quote on my position on screening men. It hasn't changed since the BS I received for taking a position of agreement with a guideline that, to me, is still the best screening guideline based on science. As weak as they are at this point, I do expect molecular biomarkers to be included in the 2023 review and there may be changes to statements on younger men. Whether I serve on that panel or someone else, without better studies, improved biomarkers, or better education, I would not expect any changes.
Off my soap box.
Take care, get educated, discuss with your kids because if you want to help them, you have to.
(A couple changes made to mistyping)