Posted by: notdeaddinosaur | October 19, 2014

Guidelines be Damned

The urologists have done it again:

Patient’s [non-prostate-related urological issue] is resolved. Annual prostate cancer screening with PSA and DRE emphasized. [sic] Re-check in one year.

Prostate cancer screening guidelines; FOUR of them: from the American Cancer Society, the American Urological Association, the American College of Physicians, and the United States Preventive Services Task Force. Go ahead; click through; read them.

Central to EACH AND EVERY ONE is the concept of “shared decision making,” recognizing that “[t]he benefits of screening with the prostate-specific antigen (PSA) test are outweighed by the harms for most men.” (American College of Physicians)

Here it is again:

The American Cancer Society (ACS) recommends that men have a chance to make an informed decision with their health care provider about whether to be screened for prostate cancer. The decision should be made after getting information about the uncertainties, risks, and potential benefits of prostate cancer screening. Men should not be screened unless they have received this information. [emphasis mine]

Oh, but that’s just from a bunch of people who don’t actually take care of patients with prostate cancer.

Okay. Here you go. Guideline statements from the American Urological Association (that would be the folks who do actually take care of patients with prostate cancer):

Guideline Statement 1: The Panel recommends against PSA screening in men under age 40 years.

Guideline Statement 2: The Panel does not recommend routine screening in men between ages 40 to 54 years at average risk.

Guideline Statement 3: For men ages 55 to 69 years the Panel recognizes that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, the Panel strongly recommends shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man’s values and preferences.

Guideline Statement 4: To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce overdiagnosis and false positives.

Guideline Statement 5: The Panel does not recommend routine PSA screening in men age 70+ years or any man with less than a 10 to 15 year life expectancy.

[all emphasis mine]

Nowhere in 2014 does anyone responsibly “emphasize” annual prostate cancer screening with PSA and DRE. Nowhere. Nowhere, apparently, except in the offices of stubborn specialists refusing to relinquish their old ways. They literally have their patients by the balls (well, close enough.)

I’ve addressed this before. Twice, in fact. To say I was dismayed to receive the letter above is like saying T Rex can be a bit excitable when he smells food. To keep to the subject at hand, let’s just say I’m really really pissed.

When I started practicing, it was standard procedure to treat upper respiratory infections with antibiotics. Knowledge grew. Recommendations changed, and I stopped; even when patients didn’t understand and I had to take time and make the effort to explain it to them.

What good is it to do research and make new discoveries when no one pays any attention to the findings?

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Responses

  1. Unfortunately it is the general norm for the medical community to ignore research and discoveries, no matter what specialty you are dealing with.

  2. Reblogged this on karenpriceblog and commented:
    Oh yes the debate rages on except that its not a debate. I do think we as GPs need to inform educate and teach our patients about the (mis) information around. Primum non nocere. Thats our job. Also a quick peruse of the word Physician and Doctor from Wikipedia so correct me if I am wrong!! The appellation of “Doctor” (from Latin: teacher) was usually awarded only when the individual was in middle age. It indicated a life dedicated to learning, to knowledge, and to the spread of knowledge. The word TEACHER being key. Following this debate and its politics with interest.

  3. Amen.

  4. Brava!

  5. I share your concern. I live in fear that my 75-year-old, diabetic, hypertensive, hyperlipidemic dad with BPH will have an elevated PSA on “routine screening” at his urologist’s office.


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