Is “Watchful Waiting” the best approach for Your Prostate Cancer? There is now a genetics test that can help answer your question.
1. PSA Screening Declines Following Government Mandate
In late 2011, the US Preventative Service Task Force (USPSTF) recommended against routine PSA screening to detect prostate cancer in men without symptoms. A new study from the Brigham and Women’s Hospital at Harvard, authored by Dr. Michael Zavaaski and colleagues, analyzed 27 million primary care visits by men ages 50-74 years old. The major finding was a 57% drop in PSA screening by primary care physicians compared to only 4% in PSA testing by urologists. Their study was published in the February 8, 2016 issue of JAMA Internal Medicine. Dr. Zavaaski’s study compared PSA testing from 2010-2012, before and after the USPSTF guidelines were issued. So it appears that primary care physicians really took the Federal government’s recommendation to heart.
Although I believe these results are dramatic, Medicare or CMS is now considering actually imposing a penalty on doctors who order PSA tests that do not meet the Federal government’s standards. Certainly this is an unprecedented action and represents a very slippery slope for doctors as well as patients. My fear is that the bed rock of medical practice-the concern and loyalty of a doctor to his or her own patients-will be trampled upon by the Federal government. Doctors will now be judged and paid not by attention and concern for the individual patient sitting in front of them, but rather by how doctors treat “populations of patients.” This is a profound shift in the doctor-patient relationship. And it is already in Dayton, Ohio. I just smiled when I received a request from one of the region’s hospitals to attend a new seminar entitled “Treating Populations of Patients in the Future.” To me patients are people, not ‘populations’.
2. Breakthrough Genetic Testing May Help You Choose the Best Prostate Cancer Treatment for You
For those men who already have been diagnosed with prostate cancer, hope is on the way. A number of genetic tests on the prostate cancer itself can help you and your cancer specialists judge whether you need treatment or not. Once such test is the Oncotype DX prostate test. The Oncotype score can be added to cancer stage, PSA level and Gleason score to help estimate how likely your prostate cancer is to spread to bone-a fatal complication. I think the Oncotype adds key information that can help you decide whether a watch and wait approach is good for you.
Dr. Evans and colleagues looked at the genetic profiles over 1000 prostate cancers in men with high risk features. Their study showed a number of genes responsible for DNA damage and repair may be used to help select those patients who need more than standard surgery or radiation-options like adding chemotherapy or hormonal therapy or both. Their study was published in the Journal of the AMA Oncology January 7, 2016 issue.
And don’t forget-not all men have early-stage prostate cancer. Now that routine PSA screening has declined, many patients are referred to urologists and radiation oncologists with high risk prostate cancer. Men at high risk are those with a Gleason score 7 prostate cancer and a PSA of greater than 10 ng/ML or a Gleason 8-10 prostate cancer regardless of PSA level.
So What’s a Man to Do?
From my experience as a cancer specialist as well as the patient, no man looks forward to the annual digital rectal exam. Or even a needle stick in the arm for routine blood work. But I would not be so quick to throw out either test so fast, despite what the Federal government says. I still may be a “true believer” but I still hold that my job, my obligation if you will, is to the patient sitting in front of me, and not to the Federal government. If my brother or father had prostate cancer, I would certainly be tested with PSA and undergo a yearly digital rectal examination. As a cancer specialist, it is remarkable to me that Medicare wants to halt PSA testing while, in the next breath, President Obama is launching a new “Moon Shot” in the war against cancer. With all the talk about precision medicine, I hope that personalized medicine-putting the patient first and foremost-is not forgotten altogether.
If you have been denied a PSA and think you need one; or you have an elevated PSA and are not sure if watchful waiting is best for you, give me a call to set up a visit at 855-DAYTON1