USPSTF’s PSA recommendations prove criminal!

USPSTF’s PSA recommendations prove criminal!

Not before time, researchers are looking closely at the impact of the USPSTF advisories to stop (2012) or limit (2016) PSA screening. Back in the day, PCa advocates submitted our comments warning exactly of the morbid findings you can read below. It ain’t brain surgery to work out that:

“These data illustrate the trade-off between higher screening rates and more early-stage disease diagnoses (possibly overdiagnosis and overtreatment) and lower screening rates and more late-stage (possibly fatal) disease,”

Problem was, there were no brain surgeons on the USPSTF Panel in 2012… neither were there any urologists if my memory serves me right,. The Chair was a pediatrician!

These stats upset the PCa advocay community greatly. We are the ones working with younger men, often with kids in their tweens and teens, who wonder if they will see them graduate high school, never mind college. Some of you know that AnCan (https://ancan.org) suports a virtual group specifically for men under 60 with advanced PCa in respnse to the need we have identified.

What good does “We told you so” do as we see PCa specific deaths mount. What USPSTF did was criminal – it has resulted in a significant uptick in PCa specific deaths estimated by ACS as increasing 25% in number over the past 4 years. If nothing more, USPSTF should apologize and take responsibility. They were forewarned!

 

Advanced Prostate Cancer Cases Continue to Rise in U.S.

— Lasting effect of USPSTF’s 2012 recommendation against PSA testing

Coinciding with declines in prostate-specific antigen (PSA) screening over the last decade, the incidence of intermediate- and high-risk prostate cancer has continued to increase across the U.S. in men 50 and older, a nationwide, population-based analysis has shown.

From 2008 to 2012, ahead of the United States Preventive Services Task Force (USPSTF) recommendations against PSA testing for prostate cancer, incidence of distant-stage disease was increasing by 2.4% per year for men 50 to 74 years. But this more than doubled to 5.6% per year from 2012 to 2015, reported Ahmedin Jemal, DVM, PhD, of the American Cancer Society in Atlanta, and colleagues.

Their analysis in the Journal of the National Cancer Institute also found that in men 75 and older, incidence of distant-stage prostate cancer increased by 5.2% per year from 2010 and 2016.

In contrast, incidence of local-stage disease decreased by 6.4% per year in men 50 to 74, from 2007 to 2016. And in men 75 and older, declined by 10.7% per year from 2007 to 2013, and then stabilized.

From 2009 to 2016, the researchers estimated that 11,387 more men were diagnosed with distant disease than would have been diagnosed had the incidence rates remained at their 2008 nadir. But 633,111 additional local cancers would have been diagnosed from 2008 to 2016, had rates for local disease remained at their 2007 peak.

“These data illustrate the trade-off between higher screening rates and more early-stage disease diagnoses (possibly overdiagnosis and overtreatment) and lower screening rates and more late-stage (possibly fatal) disease,” the investigators wrote. “The persistently increasing regional- and distant-stage prostate cancer incidence during the past 5 years has public health implications given the substantial morbidity and premature mortality associated with it.”

Starting about 5 years ago, investigators including Daniel Barocas, MD, MPH, of Vanderbilt University in Nashville, began documenting a decline in the incidence of localized prostate cancer and hinted at a rise in the incidence of non-localized disease in the wake of the 2012 USPSTF recommendations against PSA-based screening.

“The study by Jemal et al actually quantifies the trade-offs associated with this policy,” Barocas told MedPage Today. By 2016, localized cases — representing a combination of “overdiagnosed” low-risk cases and higher-risk localized cases that are destined to progress — had declined by over 115,000 per year.

At the same time, “non-localized (lethal) cases had increased by over 3,500,” Barocas wrote in an email. Although the USPSTF updated the recommendations for PSA screening in 2018, suggesting that decision-making for PSA-based screening should be “individualized” for men ages 55 to 69, “decoupling” the diagnosis of localized disease and treatment did not seem to reduce the survival benefit associated with screening, he added.

Furthermore, “urologists, all reputable guideline bodies, and increasingly the public, have embraced the concept of observing low-risk prostate cancer. And continued efforts to improve the specificity of screening and to increase the use of observation for low-risk disease will preserve the survival benefit and reduce metastatic disease associated with screening while minimizing the harms associated with overdiagnosis,” Barocas continued.

For the new study, all prostate cancer cases diagnosed from 2005 to 2016 were obtained from the U.S. Cancer Statistics 2001 to 2016 Public Use Research Database, which covers 100% of the U.S. population. Men were stratified by disease stage, age, and race/ethnicity.

Incidence of local-stage disease in men 50 and over increased from 456.4 to 506.1 per 100,000 from 2005 to 2007, and then plummeted to 279.2 per 100,000 by 2016, Jemal and co-authors reported.

In contrast, incidence of regional-stage disease generally increased across the same study interval, from 5.7 to to 9.0 per 100,000 men from 2005 to 2016. For distant-stage disease, incidence rates declined from 23.1 to 22.4 per 100,000 from 2005 to 2008, but then increased to 29.7 per 100,000 men by 2016.

“For all races/ethnicities combined, the incidence patterns for age 50-74 and ≥75 years are generally similar to those of age ≥50 years, with the incidence rates after the late 2000s declining for local-stage disease but increasing for regional- and distant-stage disease” — the one exception being for men 75 years of age and older, among whom the incidence of local-stage disease stabilized from 2013 to 2016, Jemal and co-authors noted.

Jemal and co-authors also noted a “substantial decline” in the racial disparity in the incidence of distant disease in black and white men age 50 to 74. But this coincided with a steeper increase in the incidence of distant disease in non-Hispanic white men over the study period, and the incidence of distant disease in non-Hispanic black men still remains two to three times higher than in non-Hispanic white men among those under 75, and is 65% higher in men 75 and older, the researchers noted.

“The harms associated with high PSA screening rates can be mitigated while preserving the benefit of screening through PSA-stratified strategies including longer screening interval based on baseline PSA, higher PSA threshold for biopsy referral in older men, and restricting routine testing to men age ≤70 years,” the team wrote. “And future studies are needed to elucidate the reasons for the rising incidence trends for regional- and distant-stage disease and for the disproportionately high burden of the disease in black men.”

Asked for his perspective, Thomas Ahlering, MD, of the University of California (UC) Irvine, noted that he and his colleagues have documented a similar pattern of prostate cancer incidence rates as an unintended consequence of decreased PSA-based prostate cancer screening. In a 2018 study, the team found that the proportion of low-grade prostate cancers decreased significantly from a pre-recommendation average of 30.2% in 2012 to an average of 17.1% in 2016.

In contrast, the incidence of high-grade cancers with Gleason scores of 8 and over increased from a pre-recommendation low of 8.34% to a post-recommendation high of 13.5%. There was also a 24% increase in absolute numbers of Gleason 8 and above cancers in the post-recommendation interval.

“The major difference between this study and our own is that their study is clinical and ours was pathological, meaning it used a surgical database,” Ahlering told MedPage Today. “We were picking up much more regional disease with metastatic potential.”

This regional disease — which can be thought of as intermediate risk, he said — is much more burdensome for patients and especially for the healthcare system, because it usually necessitates some form of secondary intervention. And that secondary intervention likely costs about the same as the first intervention cost — i.e., around $40,000 per year.

Linda Huynh, MSc, also of UC Irvine, noted that research from Ruth Etzioni and colleagues has shown that if PSA screening were continued, but only for men younger than 70, more than half of avoidable cancer deaths could be prevented, while at the same time the strategy would dramatically reduce overdiagnoses compared with continued PSA screening for all ages.

“Etzioni has said, and we applaud it: ‘Discontinued screening for all men eliminated 100% of overdiagnoses but failed to prevent 100% of avoidable cancer deaths,'” Huynh said. “So it really is a matter of systematically screening first, and then you can worry about overtreatment and complications from treatment after the cancer is diagnosed.”

Ahlering also noted that screening recommendations may be “tinkered” with as much as anyone might like, but what is really needed are centers of excellence where prostate cancer is expertly treated: “The initial intervention for a man with prostate cancer needs to last 22 years or more,” he said. “So how a patient gets treated is as important or more important than anything else — that is what we are pushing for at least — you just can’t pull the plug and stop doing PSA screening.”

Disclosures

The study was funded by the American Cancer Society (ACS), and the authors, ACS employees, noted the ACS receives grants from private and corporate foundations, including foundations associated with companies in the health sector for research outside of the study, and that the authors are not funded by any of these grants and their salary is solely funded through ACS funds.

Neither Ahlering nor Huynh had any conflicts of interest to declare

Barocas disclosed relevant relationships with Astellas, MDxHealth, Janssen, and Tolmar.

Advisor Kudos to Howard Wolinsky!

Advisor Kudos to Howard Wolinsky!

Congrats to AnCan Advisor and  Active Surveillance Prostate Cancer Virtual Support Group Moderator, Howard Wolinsky, for receiving the Best In-depth Report or Series Lisagor Award from the Chicago Headline Club  for his article in Chicago Medicine on “The debate over gadolinium-based contrast agents

For those who attend this group, they are well aware that gadolinium contrast is a frequent topic of conversation. This may have even spurred Howard into his excellent in-depth report on the dangers associated with the use of this scanning contrast.

Onward & upwards, Howard ….. keep generating that social profit!

USPSTF’s PSA recommendations prove criminal!

Hi-Risk/Recurrent/Advanced PCa Men & Caregivers Recording – Apr 28, 2020

Pick of the Week:  First and last this week ….. prednisone may have optical side effects; and, using Lu177 very early in the metastatic disease cycle.(rd)

Prednisone side efects on eyes and more; Covid19 making you stir crazy?; Doctor/lab visits during Covid19; Getting treated home and away; Xgeva users survey pays well; getting used to ADT; starting salvage radiation; should a GU med onc lead your team?; very early Lu177 vs hormone therapy

Chat Log 

Len (to Everyone): 3:21 PM: Xgeva patients:  Patient Interview Eligibility Questionnaire

AnCan – Rick (to Everyone): 4:17 PM: len@ancan.org

AnCan – Rick (to Paul Freda): 4:58 PM: We see ya …. looking v. good w/o a moustache!!

Paul Freda (Private): 4:59 PM: Oh gosh I have not had a mustache for years. Maybe when I was living in Bangkok 5 yrs ago. ??

Paul Freda (Private): 5:02 PM: My blood test came back in one day. Cheers … still in remission.

AnCan – Rick (to Paul Freda): 5:05 PM: Yeah …….

AnCan – Rick (to Paul Freda): 5:07 PM: We’ll get to you next week -promise

Paul Freda (Private): 5:08 PM: No problem. I was just going to mention a great documentary on Jim Allison, the Nobel Prize winner who is now at MD Anderson. He is responsible for many CURES with Ipilimumab. Really interesting guy.

Advisor Kudos to Howard Wolinsky!

ASKING FOR HELP …… & that includes the male gender!!

Peter Kafka, our Board Chair, is currently in the midst of chemo. He relates first hand why men must to get off their high horse and ask for help – it can solve many medical problems simply!  (rd)
ASKING FOR HELP

Why is it so difficult for men to ask for help?  Perhaps many men view it as a sign of weakness if we can’t handle a challenge on our own.  I have had plenty of occasions to ask myself this question over the past number of years.  In terms of changes in my body and internal mechanisms I have noticed that I can “put up” with many things for long periods of time under the belief that whatever it is that is going on will go away or I will adapt to the changes.  When I think about it now, I realize that this is a pretty stupid approach.  An independent nature can get one in big and unnecessary trouble.

For many months before I was diagnosed with Prostate Cancer, I was symptomatic with urinary retention.  In simple terms, I could not piss.  This is not a normal condition which I knew, but somehow, I talked myself into believing that it was a sign of aging and probably nothing more than an enlarged prostate.  It did not help that my urologist was not very attentive and did not give much more than a passing thought and a prescription for Flowmax for my condition.

After months of pushing on my gut in order to force out small amounts of urine to take the pressure off my bladder, it was a close friend who pushed me to seek medical help.  I did, and as they say; “The rest is history”.  But I went through many months of needless discomfort and agony before I humbled myself enough to seek help.  Was it embarrassment? Arrogance? Independence? Perhaps a bit of all of these that kept me from asking for help.

I mention this because I am still learning thIS great lesson.  In my current regimen of chemotherapy, I have noticed marked changes to my vision.  My first thought (self-diagnosis again) was that it must be cataracts.  Perhaps the chemo was accelerating this “natural” phenomenon that comes with aging for many of us in our 70’s.   But the changes in my vision were substantial and rapid enough that I thought it would be worth mentioning to my medical oncologist during a recent telephone consult.  I included this item in my list of “talking points” which I put together for each and every one of my medical appointments.  It is too easy to forget stuff.  I have learned this the hard way.

The answer came quick.  It was not the chemo; it was the Prednisone.  Sure enough, when I searched out the side effects of Prednisone, the blurry and cloudy vision I experienced was one of them and even at the low dose I was taking.  I inquired about why I needed this steroid, I was told that for some it helped stimulate appetite and energy levels.  With my doctor’s approval I weaned myself off the prednisone and decided that I would try and continue my chemo regimen with out it. 

So, I guess I am still learning the great lesson:  Be your own best advocate and ask for help!

Join SUPER HealtheVoices Live this Saturday, April 25 – all invited!!!

Some of you may already be aware of Janssen/J&J’s annual patient advocate conference, HealtheVoices, that is usually by invitation only based on a competitive application process. This year’s pandemic has sent the Conference virtual, and it is open to ALL! The conference covers the spectrum of conditions from mental to physical, and from cancer to rare diseases.
#HealtheVoicesLIVE 2020 is this Saturday, April 25 starting from 11 am – 8.30 pm Eastern. You can find the full agenda and link to join HERE. Feel free to pop in and out during the day and tune in to presentations and events of interest to each of you.There are presentations, interviews and even small group breakouts allowing you to interact with leading national advocates for differing conditions.
Please note the links to join change for the morning and afternoon sessions:

To join the broadcast between 11 a.m. and 3:30 p.m. ET, click this link.

To join the broadcast between 3:30 p.m. and 8:30 p.m. ET, click this link.

For the best experience, join the meeting via Google Chrome

I will be presenting in the 3rd Hour; the session starts at 1.30 pm Eastern and I am due up first as part of 4 flash sessions followed by a Q&A. I will be offering tips on virtual moderation – a skill many patient advocates have had to quickly familiarize themselves with in the past few weeks. But as you all know, we’ve been at this game for many years!!
Please join me and HeV, enjoy the conference, learn a little, and above all – stay safe, well and have fun!
Onward & upwards, rd