U.S. task force putting men at risk for prostate cancer? Doctor discussed.

Oct 07, 2011

The U.S. Preventive Services Task Force has concluded that most men should not routinely get a widely used blood test to check for prostate cancer because the exam does not save lives and leads to too much unnecessary anxiety, surgery and complications.

Dr. Deepak Kapoor disagrees. Kapoor chatted about why he thinks this federal task force is putting the health of men at risk.

Read: Healthy men don't need PSA testing for prostate cancer, panel says

Good Afternoon.


This is Deepak A. Kapoor, MD, Chairman and CEO of Integrated Medical Professionals, the largest urology group in the United States, and President-Elect of the Large Urology Group Practice Association.


I am here, along with Dr. Carl A. Olsson, John Latimer Professor Emeritus of Columbia University School of Medicine, to discuss questions regarding prostate cancer, diagnosis, screening and treatment

I question whether most people would rather risk dying a horrible cancer death than undergo a screening and subsequent treatment if cancer is found. The study doesn't deny that a PSA test is a reliable test for the presence of cancer cells in a man's prostate gland. And the test, which is often done with a routine blood test for diabetes and cholesterol, costs only a few dollars. So why shouldn't the test be routinely done? - Post commenter billeisin1

The fundamental problem with the study is that they extrapolate screening into treatment.  Screening in and of itself provides information to doctors and patients; there is virtually no risk to the screening process.  Once screened, the decision for biopsy, and ultimate treatment is between physician and patient, and needs to be customized for every circumstance.

Recommendations of such magnitude should be accompanied by the associated report, especially when said document is rumored to be twice the length of War & Peace. Who is on this committee? Why are we not permitted to learn the basis of their ukase?

Good Point.  One of the issues with prostate cancer statistics is that traditional followup (5 years) is simply too short to determine if any treatment (or screening) is effective.  The reality is that longer term data (both from Europe and the United States) indicates that there is a significant survival advantage to patients that are screened vs. those that are not.

It's easy to say "early diagnosis saves lives!" but it's much harder to prove. They made this recommendation because clinical trials showed that prescreening for prostate cancer doesn't save lives.  Do you discount those clinical trials?

Actually, it is not that difficult to demonstrate.  The incidence data regarding prostate cancer demonstrates that despite increased screening efforts, the incidence of prostate cancer is more or less flat, while the death rate per 100,000 population has declined by nearly 40%, suggesting that we are detecting this disease earlier and saving lives.


Unfortunately, the control arm in the PLCO trial, which is widely quoted, were patients receiving "usual care," not no screening.  In the control arm 55% of patients actually were screened for prostate cancer!  Thus, from a scientific standpoint, the methodology of the study is troubling.


A better analysis, performed by Hugosson in Goteborg, with over 9000 patients in each arm, showed a 44% decrease in prostate cancer  deaths in those patients that were screened compared to unscreened at 14 years mean followup.

So how do we, the men that this effects, complain? To Whom? How do we stop this non-screening recommendations from becoming actual procedure. - Post commenter RaysZ28_2009

This is the most important point of all.  Two years ago, this same panel made a recommendation that would prevent women from getting mammograms, and the resulting outrage stopped implementation.


If these guidelines are implemented, we will undo 20 years of progress, and thousands of men will die unneccessarily of prostate cancer.  All of us need to email, write, fax or phone our elected representatives in Washington to let them know that adoption of these recommendations places the lives of all men, particularly high risk patients (such as African Americans and those with a family history of prostate cancer) in jeopardy.

So, basically should we ignore this report? What value is it? As long as one follow up on high readings with other more detailed tests such as Free PSA, PCA3, and observe the PSA velocity, what harm does routine screening poses? It would seem to me for the people who have prostate cancer, it is best to know as early as possible so the cancer can be treated before it spreads beyond the prostate gland. I think eliminating this risk is worth some anxiety over the test results as you can followup always with more specific tests even before getting a biopsy which may not be even necessary.

Unfortunately, none of us can afford to ignore this report.   If third party payors and the government adopt these recommendations and refuse to cover  PSA and digital rectal examinations as part of routine men's health, the impact on access to care will be devastating.

Is this numbers/money/insurance game. At 35 my husband had slight PSA, had a feeling and insisted on biopsy. Sure enough, cancer (early,early stage).  I believe prostate removal is giving us a long life together!

First, let me congratulate you and your husband on his surviving this disease, and applaud you for participating in your health care decision making.


PSA is a tool, and like any other tool, must be wielded by individuals with skill and experience.  No patient should have "cookie cutter" medical therapy, and all screening does is provide information that better helps patients and their doctors decide what to do next.  Screening is not surgery, nor radiation, or even active surveillance; it is simply screening.  Once screened, the physician and patient decide whether any further intervention is appropriate or warranted, and then proceed from there.  Any suggestion that more information to help empower patients in their personal health care choices is inappropriate is simply irresponsible. 

Dr. Moyer has only published on Pub Med 76 articles, 27 by my count being specifically listed as U.S. Preventive Services Task Force publications, 2 being Cochrane reviews. No epidemiological studies to speak of. Many of the remaining articles are reviews or forwards or announcements of editorial policies. Is this something resembling this video about never having been to sea.

I'll respond with a personal anecdote.  As a resident in Urology in the mid 1980's, over 40% of patients presented with cancer that had already spread (metastatic)...these patients were doomed from the start, and as a physician, I stood with these men and their families as they died.  Now, virtually every patient detected early is treatable.  To be able offer hope, and the opportunity to live out the natural span of life, is something that we have accomplished with this disease, and should be protected.


To your point specifically...while I do not know the members of this task force, not one is a practicing urologist.  The recommendations of this group certainly does not represent the opinions of doctors that care for this disease every day.

So... their recommendation is what -- wait until a tumor is large enough to detect with your doctor's finger up your patoot?  Personally, I have had a couple of friends die of this horrible disease and four more saved because they detected the cancer early via the PSA test.  
The insidious part of this study is that it seems to revert to that old, macabre maxim that all men will get prostate cancer if they live long enough. It seems as though the panel just wants nature to ta
ke its course. Why bother with prevention -- let's just terrorize men with enough uncertainty that they will die off before the desease strikes.  - Post commenter DOps

We can't disregard the importance of a digital rectal examination (the medical term for a finger in the patoot!) in detecting prostate cancer, as a substantial percentage of men diagnosed with this disease have normal PSAs.



The bottom line is that the most common symptom of prostate cancer is no symptom at all, and the only way to detect the disease early is to proactively look for it.


The discussion on who needs treatment for prostate cancer  is ongoing.  As men live longer, more productive lives, some of the historical paradigms we used simply are no longer relevant.  With safer, less invasive modes of both radiation and surgery, treatment can be offered to men that previously were not candidates, and more recent data shows that proactive treatment improves survival even in older men, a subgroup who this group recommends not even evaluating for prostate cancer.


We are in a time of unique challenges in healthcare, and for the first time physicians in the United States are being told that cost of care may be more  important than saving lives. 


When we evaluate any recommendations for screening or treatment of prostate cancer, or any other disease for that matter, we must ensure that there is a balanced review of the literature, that is conducted by individuals experienced in managing that disease.  Only in this way can we ensure proper critical analysis of scientific methodology, and produce recommendations that are informed, scientifically valid and responsible

In This Chat
Dr. Deepak Kapoor
Dr. Deepak Kapoor, is President of Advanced Urology Centers, the largest urology group practice in the United States. He has been featured and interviewed by news media outlets throughout the country talking about Prostate Cancer and has published and lectured extensively on both clinical and business medical issues. Dr. Kapoor is President-Elect of the LUGPA, Large Urology Group Practice Association. To learn more about Advanced Urology Centers of New York call 855-Dr-Urology or visit www.aucofny.com.
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