But--is it really "choosing wisely"?

[dentaltwin]

I know, I know, the "downstream harms" of screening. But since I've been looking at these boards I've been struck by the number of men in their 50s and even 40s with advanced disease at diagnosis. Knowing that, it's no shock to me that the uptake of the recommendations from the "Choosing Wisely" campaign has not been high. So how "wise" is "Choosing Wisely"?

medpagetoday.com/reading-ro...

[BerkshireBear]

Pretty much agree with you. While the studies found some real problems with misguided and overtreatment my sense is that instead of correcting the reaction, they focused on their cure on eliminating knowledge of the cause. If you don't know about PCa you won't treat it, so raise the age of first testing. Would it not be better to keep doctors up to date on latest findings and retrain them on best approaches. Alas, as long as doctors in our USA system are rewarded ($$$) by the number of procedures they perform they will tend to over-react and over-treat. The guidance ebbs and flows but the tide is driven by monetary forces. The tests are inexpensive, especially contrasted to the immense QOL losses for those young guys.

[dentaltwin in reply to BerkshireBear]

There is a lot of emphasis on the psychological stress of a diagnosis, and I understand that--anxiety should be my middle name, and my anxiety rises every time a psa draw approaches. I suspect the pendulum will swing back, esp. as more men are diagnosed at advanced stages. And obviously we need better tests that will predict the behavior of tumors. That, together with active surveillance for low-risk disease, should greatly lessen late diagnoses. I'll still be anxious though.

[Hidden]

Yes over treatment by doctors is a problem but performing fewer screening tests for prostate cancer is the totally wrong 'solution'. I think men, starting in their 40's, need to be educated as to the dangers of not getting screened annually for prostate cancer as that opens the door to the disease becoming advanced when symptoms that can no longer be ignored show up. Who is this on? General practitioners not doing their job, not putting on the latex glove for icky DRE's? Not even including PSA tests in the labs? Is it on the patients who opt out of these screening tests and don't get annual physicals and don't like to see doctors unless they have to? Why isn't there a public service campaign to encourage men to get screened? Oh, afraid of that over-treatment bugaboo again? Afraid of disturbing a man's peace of mind with an early prostate cancer diagnosis? Beats the hell out of a late and more dire diagnosis, in my mind.

[dentaltwin in reply to Hidden]

It's all in how you balance the benefits with the "harms". It's silly (I think) that trying to make an equivalence between anxiety, stress, incontinence, impotence on the one hand, and the downside of late diagnosis can be anything but subjective. You may save only (!) one life for every 1000 tests (whatever the number is) while causing some larger number of men having incontinence, impotence or other sequellae of definitive treatment, but if that life is yours, for you it's 100%. So while I've viewed the recommendation of the USPSTF to discuss this with your doctor and make an "informed" decision as essentially a cop-out on their part, I can't think of anything better.

[Hidden in reply to dentaltwin]

The over-treatment is on the Urologists and maybe radiation oncologists and maybe even the mis-informed patients. The new reality is that more men are showing up metastatic at diagnosis because they weren't adequately screened. Not me. I insisted on annual DRE's. I was diagnosed early and chose a less invasive treatment option that one of the stars here likes to hate on -- HIFU. No impotence or incontinence here. Doing fine 5 1/2 years post HIFU.

[dentaltwin in reply to Hidden]

I'm glad you're doing well. The thing is--on a population level maybe you can say some men are "overtreated", but on an individual basis there's no way to know (unless the pathologist screwed up big time and it's discovered later)--no more than you can know whether you'd have been better off with another mode of treatment.

[Hidden in reply to dentaltwin]

What you say is true with regard to treatment options. My main point is that the best way to prevent over-treatment isn't under-screening. Screening is cheap and finds disease when it is more easily (and cheaply?) treated. How can that be a bad thing? Why wouldn't universal screening of men, starting in their 40's, be the goal? What happens after that, when disease is found, well that needs to be figured out. Surgeons (urologists) are always going to want to perform surgery. It's what they do ... even when not warranted or less invasive modalities like ADT would do the job with less risk of the nasty quality of life consequences we hear too much about. I guess I'd refer to the Dr Scholz' "Invasion of the Prostate Snatchers" as exhibit A in my argument.

[dentaltwin in reply to Hidden]

Well, of course if you're the USPSTF what happens after that is the problem. I don't have to tell you that "overdiagnosis" is a rather slippery term. AFAIK, ADT is not primary treatment for localized disease, and certainly isn't without its own set of QOL issues.

To my mind, if you allow that a certain number of PC cases are indolent and do not need treatment, then a screen that can predict which cases WILL need treatment could address at least part of the problem.

[Hidden in reply to dentaltwin]

Isn't that what we call the Gleason score? Of course that requires a not so pleasant biopsy. So a biopsy can be considered part of the screening process to determine the seriousness of the situation.

[dentaltwin in reply to Hidden]

Screening is something done at the population level to detect people at risk. Biopsy is not considered a screening procedure--it's a diagnostic procedure used to guide treatment.