The USPSTF - United States Preventive Services Task Force is making an update to the 2018 Prostate Cancer Screening Guidelines. There are many sections of the "public comments" section that you can share your opinion for the screening guideline updates. Hopefully you agree with better and more robust guidelines like women have for breast and cervical cancer screenings that are part of their yearly screening for free.
We know that the USPSTF 2012 "D" recommendation of "Do not use prostate-specific antigen (PSA)–based screening for prostate cancer. Grade: D". Keck Medicine of USC study shows that the incidence rate of metastatic prostate cancer rose as much as 43% in men 75 and older and 41% in men 45-74 after routine prostate cancer screenings were no longer recommended.
The 2018 USPSTF recommendation of C / D were really of NO significance: Have a talk with your doc starting at age 55 to see if screening is right for you (most language bundles treatment risks and side effects with screening), "In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of family history, race/ethnicity, comorbid medical conditions, patient values about the benefits and harms of screening and treatment-specific outcomes, and other health needs".
While the over diagnosis and over treatment are true with the early days when 30 - 35% of the men being treated with prostatectomies were age 75+.
What is missing, in my opinion and I hope in many of yours, is the opportunity for regular screening starting at age 45. There are many great age stratified recommendations by many of the big teaching hospitals and also the NCCN - National Comprehensive Cancer Network.
One thing ALL agree on is that early detection of prostate cancer provides the greatest opportunity for treatment and possible cure.
Right now, men under 55 are an acceptable loss to the healthcare system but these men would most likely receive great benefit of early detection given a 25 - 40 year life span ahead.
I, myself, are part of the 2012 USPSTF disastrous recommendation that has backfired with the 41% increase of advanced disease at diagnosis. I was steered away from screening and not given the opportunity in 2014 - do not use psa testing for prostate cancer testing. I felt like I had dodged the bullet when I had no family history. The doc said that I may get it when I am much older in my 70's - 80's because of age. So he tested my testosterone level for early onset of ED and his conclusion "likely psychological" but did not factor in low libido, low testosterone, fatigue and I was in the best shape of my life (46) as I had just biked 3,600 about 4 months before. The simple psa test could have made a huge difference in my prostate cancer journey!
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Cyclingrealtor
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I also think the testing should start sooner for people in certain jobs- like the military, police, sanitation workers or firefighters. They are exposed to cancer causing chemicals daily. It’s been proven to build up in your body. Testing sooner might be able to stop the spread.
How about some basic numbers that GPs could provide to patients/men....eg, number needed to treat to reduce annual deaths by one. And, some type of data re probablities of various side effects from various treatments? Alll the necessary info to form a good basis for a patient's decsion to test or not !!! Maybe a brochure for each man to review and then decide????
GP biases should not factor into each man's decision to test or not!!!
The GP's already have those numbers by the USPSTF.
That's where the GP's get their data.
That's why screenings dropped 60%+.
Are you familiar with the USPSTF and their role in healthcare policy?
If not, I highly encourage you to read through the 1996, 2002, 2008, 2012 and 2018 prostate cancer screening guidelines and their research and studies they use for their conclusions.
Read the 2012 European Urologic Association letter about the USPSTF studies and data. There's so much wrong with the PLCO trial not only pointed out by them but major US research hospitals.
Are you familiar with the design flaws and contaminated groups of the PLCO trial?
Are you familiar with the fact that over treatment and over diagnosis was referring to men 75+ who were having RALP's? 35% of RALP's were men 75+?
Why is metastatic disease at time of diagnosis up 41%+ from 2010 to 2018?
If you haven't taken a deep dive, I highly encourage you to look into it.
BTW, while I've never done a transcontinental cycling trip, I was an avid cyclist. After my RP it took me almost 4 years to find a saddle I could sit on with not much pain. This group (and the cycling FB page for cyclists over 60) were helpful with my search.
Hey, you seem to belive I'm opposed to testing? Nope, I am aware, though not the deep dive you have done apparently......if you read what I wrote, you would see I belive that Docs should present, thru brochure or in some manner, data so that patients can make INFORMED decisions!! can't expect millions of men to do that research before deciding !!! and what a waste of time for millions of men to each do the same reserch!!!
You and I agree on testing and shared decision making but what data?
If you look at the data the USPSTF has reviewed there was nothing in there that said in 2012 the BEST evidence was the same as the 1996 recommendation of - do not use psa testing for screening of prostate cancer.
1996 they were not using AS as a regular screening process. 35% of their prostatectomies were men age 75+. The 1996 recommendation called out and stated that the cost, something that the USPSTF isn't supposed to comment on as a concern, would be exorbitantly expensive and un affordable. PSA screening in 1996 had only been used as a screening tool approved by the FDA only a few years before. Mortality studies were only about 8 - 10 years.
So 26 years later in 2012 the PLCO trial was rushed to completion just after the Affordable Care Act was enacted and the USPSTF threw out 26 years of progress the urologists and oncologists had made with prostate cancer. The USPSTF guidelines wiped out screening all together putting men with intermediate and advanced stage progress, who would benefit from screening at great risk of disease.
It makes NO sense unless it is a recommendation to mitigate the healthcare systems financial exposure to active screening guidelines.
What USPSTF recommendations are in place for men age 40 - 55?
What USPSTF recommendations are in place for early detection?
The USPSTF recommendation provides financial and legal protection to the healthcare system. "Sorry to see your advanced stage disease at diagnosis. We're just following the national guidelines".
There is no evidence I have seen that not screening for prostate cancer is the best decision for ALL men. So what data do we use?
That is not my understanding of the guidelines......my understanding is "discuss with patient, and let the patient decide" Where does it say "do not discuss with patient" ?
I mean current guideline in effect today!! we can't change the past!
Why age 55? Does prostate cancer does not exist before then? (30% of men between 40 and 60 show histological disease)
Why does the patient need to have the conversation with their doc? They may not even know to bring up the topic.
So if I screen I can become impotent and have urinary issues? (Treatment risks bundled with screening)
If I have a biopsy I may get sepsis? (1-3% risk)
If I'm white I have little risk?
If I screen I may have anxiety? (What cancer test doesn't stir anxiety?)
If I have no family history I'm not at risk? (Germline is only a 5 - 7% risk factor)
Prostate cancer is all the same so I'm most likely going to die with it than from it? (Advanced disease is skimmed over in the guidelines)
The language in the guidelines is steering with misinformation and missing information for anyone to make a proper decision.
According to the guidelines I should not have prostate cancer.
2014 - I was steered away at age 46 - no family history - but had symptoms the urologist should have connected the dots on. Screened testosterone but not psa.
I was too young (53) in 2021 for Kaiser and their USPSTF guidelines according to my pcp. He would not have recommended screening.
I had no symptoms.
No comorbidities.
No diabetes.
Not a smoker.
Not a drinker.
Not obese.
No heart disease.
No Germline mutations.
Again, no family history.
I discovered my disease by luck. It was included in an online panel of tests I ordered.
But waiting until age 55 to have a discussion would have been best?
I was steered away from screening by all guideline recommendations at age 46 and 53.
Now at age 55 with stage 4 prostate cancer with RALP, radiation and hormone therapy confirms I wasn't presented with adequate data. It was pure luck I discovered my prostate cancer myself when I did.
I was Dx’d in 1995 at age 48, because I ASKED for the test (which is cheap) before running some distance races.
In three months my PSA went from 4.6 to 12.0. Biopsy found cancer in a couple of zones in my prostate. Had RP surgery in 1996. In my 40s!
There was a rumor (don’t know if it was true or not) that there wasn’t even a Urologist on that task force. Had my GP followed their recommendations back then, I would be dead.
I don’t trust anything they spout. This is a Capitalist economy - follow the money!
I had a GP who used PSA and DRE screening tests on me starting in my early 40's. I had a different GP in my mid-60's. He was on the faculty of a medical school and apparently felt bound to follow USPSTF guidelines. He refused to order PSA labs. I had to pester him to perform a DRE. An abnormal result on that got me sent to a urologist and a subsequent biopsy and diagnosis. My PSA was only 2.7 at the time. Something the urologist was shocked that my GP hadn't ordered. I have nothing but contempt for the USPSTF. Penny wise and pound foolish.
The USPSTF has been all over the map, of course. If memory serves (it may not) when the 2012 recommendation came out the chairperson of the USPSTF was a pediatrician. Of course, recently I read a snarky paper that screening guidelines were initially developed by doctors who stood to profit from more diagnoses. But there's got to be a happy medium between vested interest and rank ignorance.
Dr. Virginia Moyer led the study for the 2012 recommendation.
Dr. David Grossman led the study for the 2018 recommendation.
All members of the USPSTF are not urologist or oncologist. The USPSTF considers them vested stakeholders.
But the USPSTF does NOT consider a doctor of a MAJOR health care insurance and care provider a vested stakeholder.
We need progressive screening guidelines like the NCCN that are focused more towards early detection for the men who choose that path. While men who chose to roll the dice on timing can continue to follow the USPSTF guidelines. Allowing men to follow their personal preferences and values is key.
I did not know that the USPSTF had those selection criteria as official policy, but I'm not surprised. Yeah, it was Moyer that I was remembering.
I do understand the balancing of "harms" with benefits. But in my opinion it was never a really fair comparison, because the benefits of screening were always defined in terms of lives saved, while the "harms" were actually much more inclusive. Anyone spending any time around here knows there are harms of late diagnosis other than death.
We have so many tools and metrics the last 10+ years that allow doctors and patients to move forward with a biopsy if they agree.
When you read the data the USPSTF has reviewed over the years, the 1996 data stated that the costs would be $12B - $28B for the first year. Using their numbers would be $19B - $44B.
If a population based screening was approved by the USPSTF the healthcare system would have to absorb psa screening at no cost to the patient. The psa screening is not a big issue and very affordable.
It would be chasing benign issues along with prostate cancer that would add to the healthcare systems bottom line of a population based prostate cancer screening.
It's another cancer. You have to screen to see what grade is present. And move forward with the discoveries.
I disagree that Docs should just order the test, without patient discussion and informed consent, which is apparently what you suggest? In other words, should be just another standard test, like metabolic panel?
I 💯 believe it's the patient choice with good quality data that is about the facts and discussion with a urologist and/or oncologist. A primary care doc most likely has very little to no experience in diagnosing or treating prostate cancer. They regurgitate data they are given. They don't care for a prostate cancer patient day in and day out.
Not the USPSTF steering language and recommendation to not screen. Their lack of discussion of advanced and intermediate risk does nothing to inform a patient of advanced disease.
The truth is whether a doc ordered it automatically, suggests it or orders the test at patient request its the patients choice to ho through biopsy, radiation, adt, chemo, or whatever. The patient has no obligation to proceed with any treatment.
I have spoke to men who have had a doc order it with a panel and most have been grateful for knowing they are not at risk or they had a better chance of early detection.
It should be a patient choice at what age they want to start and how often they screen.
When you look at the data on population based recommendations, it's only 65 - 75% compliance of regular screening.
Primary care Docs are primarily the Docs who see patients on a regular basis...not urologists. and of course another fact not mentioned here......men as a group avoid Docs, and far less likely than women to have any kind or regular testing.
I'm glad we agree on informed consent!! Though we may have different views as far as what "informed" means re PSA testing.
From that comment, I don't think you do actually understand the task force discussions on the test. Anyway, did I say anything about NOT offering the test? No, I didn't !! How many men are treated to "save" one life ? Surely you agree that men should be given that info? Please do not continue to try and persuade me that men should have the test without asking for consent from the men.
For men aged 55 to 69 years, the decision to undergo periodic prostate-specific antigen (PSA)-based screening for prostate cancer should be an individual one. Before deciding whether to be screened, men should have an opportunity to discuss the potential benefits and harms of screening with their clinician and to incorporate their values and preferences in the decision. Screening offers a small potential benefit of reducing the chance of death from prostate cancer in some men. However, many men will experience potential harms of screening, including false-positive results that require additional testing and possible prostate biopsy; overdiagnosis and overtreatment; and treatment complications, such as incontinence and erectile dysfunction. In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of family history, race/ethnicity, comorbid medical conditions, patient values about the benefits and harms of screening and treatment-specific outcomes, and other health needs. Clinicians should not screen men who do not express a preference for screening.
The harm in screening is NO greater than ANY other lab drawn blood test!
Will the docs discuss this? In conclusion, a recommendation against PSA-based screening, particularly for men <65 yr of age with a life expectancy between 19 yr and 32 yr, on the basis of studies with <10 yr of follow-up is premature. Longer term data (ie, the Go¨teborg study) document mortality reduction of 50% and a number needed to treat as low as seven. Overtreatment can be reduced by active surveillance. The USPSTF has ‘‘thrown the baby out with the bathwater.’’ PSA, used intelligently (as suggested by Schroder [27]), has the potential to reduce PCa mortality at an acceptable cost. And when you look at most studies that are of older men, most docs will comment that the screening will most likely benefit younger men. But the USPSTF uses old outdated studies that fit the narrative that benefits the healthcare system.
Gotta love the "false positive" excuse with a man without a prostatectomy. The claim that PSA testing is not good for prostate cancer screening because it's not a cancer specific serum marker is a point shared among many but it is used in the guidelines that it's a "false positive". False positive for what? The only time PSA is a true prostate cancer marker is after a prostatectomy. We see many times that a doctor & patient chases a PSA for quite some time before locating the cancer.
Over-diagnosis and over-treatment? If a man has less than 10 years of life expectancy he should not be treated with aggressive treatment. If a doctor knowingly treats a patient when they shouldn't, it's malpractice. Over-diagnosis is a term to steer men away from screening; you have to screen to detect those who have advanced disease that needs treatment. There have been enough tools for many years to make a good conclusion on whether to move to a biopsy or NOT.
Treatment complications, ED and incontinence............ from screening?
If this is the pamphlet that you suggest should be provided, the current USPSTF 2018 guidelines, these guidelines are made to steer men away from screening. No man is forced or obligated to move forward with treatment or not.
Obviously the FACT is the guidelines have coincided with the 41% increase of metastatic disease at the time of diagnosis only through 2018. I think that is pretty good evidence that they are not working and causing more damage than good. The 2018 guidelines do nothing but cause fear and steer men away from screening.
But for the last 12 years these guidelines have protected the profits and provided legal protection for the healthcare system! "We're just following the national guidelines of the experts at the USPSTF".
There is not one cancer, especially when discovered late, that does not have side effects. It's cancer!
Why should the patient's 'guidance' take precedence over a doctor's? Patients know nothing about prostate cancer or the risks of missing early detection. What is this avoidance of screening all about anyway? Sparing a man the distress that goes with finding a possible marker for cancer? What the hell do feelings have to do with superior medical care anyway? Let's collect the data and proceed from there. The patient could choose not to be treated at that point. He shouldn't be able to choose not to get screened. That is unwise.
Yes, the choice to do something stupid, to refuse an inexpensive screening test, should face serious push-back. He can gamble with his own health but running up a giant treatment bill is a cost we all bear. Penny wise and pound foolish, the saying goes.
Again, men should have full disclosure of the harms and benefit. Of course, men are not even getting that after diagnosis and making a decison on what to do !!! But, just my experience...maybe just wrong Docs? Docs are time-constrained, and not using the tools, eg brochures and and online capabilities, to at least guide men to the appropriate data!!!!!!!!!!!!!!!!!!!!
"The guideline is NOT " do not offer this test " !!!!!!!"
Is that so? I specifically asked my GP for a PSA test. I was age 66. He refused to authorize it. He is associated with a medical school and thus, I assume, in tight with that advisory group you keep defending.
Feel free to read the actual current guideline !! I have no idea what the problem is with your GP....he is definitely not following the current guideline.
I'm talking about the guidelines in effect in 2016. Most of the men on this site were subject to the risks inherent with these earlier guidelines. I wonder how many doctors keep up with current guidelines. Probably not many.
I was in a double bind with both guidelines. 2012 do not screen. 2018 if 55+, family history, or black/ African American. 2014 and 2021 - no family history. Was only 46 & 53. I'm white.
Who know when I would have been screened if I didn't have dumb luck and order a blood panel from an online company who included a psa test.
My healthcare provider, Kaiser Permanente, is behind the horrific USPSTF guideline recommendation.
Obamacare forced the healthcare insurance to cover A & B recommendations.
Prostate cancer isn't about the risks to men anymore than other recommended cancer screenings. They all have terrible side effects that wreck quality of life.
Prostate cancer guidelines were shut down to let the insurance companies figure out how they wanted to handle it.
In fact Kaiser Permanente calls is it a "perfect natural experiment" in their 2019 study of the 2012 "do not screen" recommendation. Even in their minimal study +/- 2 yrars of the recommendation advanced disease was up 37% at diagnosis. They note how most primary care doctors use the USPSTF guidelines instead of company or organizational guidelines. Coincidentally, KP primary care docs use the USPSTF guidelines and have pop-ups letting their docs they are making recommendations outside of the national guidelines.
How do I know? I asked my doc when I would have been screened and what guidelines they follow.
There were even bills introduced at the Federal level to penalize docs for screening. Needless to say they failed.
27 years later they're still promoting the same story and narrative. They had to stop all chances of a population based screening after the Affordable Care Act, so the USPSTF lumped all of the crap together to justify their recommendation. Kaiser's "evidence" in the 2018 recommendation was only conducted by them and ASU for the over-diagnosis. The interesting fact is that it's based on "hypothesis and modeling". When you look at their reporting of 25-30% chance of over diagnosis and treatment, it's clear that they supported not to screen in opposition to the 75 - 80% who received a proper diagnosis. And let's mention the one report they reviewed that had over-diagnosis and over-treatment as low as 14%.
This is from the 1996 recommendations:
Moreover, cost effectiveness cannot be properly determined without evidence of clinical effectiveness. Nonetheless, it is clear that routine screening of the 28 million American men over age 50, as recommended by some groups, would be costly. Researchers have predicted that the first year of mass screening would cost the country $12-28 billion. This investment might be worthwhile if the morbidity and mortality of prostate cancer could be reduced through early detection — given certain assumptions, prostate cancer screening might even achieve cost-benefit ratios comparable to breast cancer screening — but there is currently little evidence to support these assumptions. The costs of this form of screening, with its emphasis on older men, is likely to increase in the future with the advancing age of the United States population the number of American men over age 55 is expected to nearly double in the next 30 years, from 23 million men in 1994 to 44 million by 2020.
There is some evidence that the recent increase in prostate screening may be generating a poorly controlled expansion in the performance of radical prostatectomies, creating an unnecessary iatrogenic morbidity in a growing population of surgical patients. The rising incidence of prostate cancer due to increased screening has been accompanied by a tripling in rates for radical prostatectomy in the U.S. If early detection and treatment are effective, they are most likely to benefit men under age 70 rather than older men. As already noted, 10-year survival for early-stage prostate cancer approaches 90%. Thus, most men over age 70, who face a life expectancy of just over 10 years, are more likely to die of other causes than of prostate cancer. Subjecting these men to the risks of biopsy and treatment is often unwarranted, and many proponents of prostate screening therefore recommend against screening after age 70. Nonetheless, studies indicate that radical prostatectomy rates for men aged 70-79 increased 4-fold in 1984-1990, and the trend appears to be continuing in this decade. Population-based rates for prostatectomy in men aged 70-79, many of whom are unlikely to benefit from the procedure, appear to be the same as in men aged 60-69. According to an American College of Surgeons survey, one out of three men undergoing radical prostatectomy in 1990 was age 70 or older.
I blame urologists for the high radical prostatectomy rates. When that surgery is the only tool in your tool box and also your 'bread and butter' why would anyone be surprised at that? Less screening isn't the answer. Fewer RP's is the answer. See Scholz' book 'Invasion of the Prostate Snatchers'. Almost every other treatment option is better than the super invasive RP.
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Update my progress posted by Formosan
Pluvicto increases radiographic progression-free survival (rPFS) before chemo
ADT (sort of) on screen
Screening for Pluvicto
What screening do I need with a PSA of 0.2?
