Whole body screening MRI/CAT scans

[Booze Aldrin]

[Edit- mostly talking about MRI here]

Anybody else thinking of doing this once you have those (hopefully) big fat attending paychecks? I'm not going to lie, after months of inpatient medicine cancer has really began to freak me out and the thought of just passively waiting and hoping I never get it doesn't sit right with me.

It's definitely not something to feasibly implement on the societal level, but it's perfectly feasible on a self-funded basis by motivated individuals. You do your initial scan to establish the baseline and hold the gun on chasing incidental findings unless they're markedly worrisome or clinically corroborated. Odds are anything you find on a first scan in your 30's has probably been there for a minute and isn't going to cause you any trouble. Then you just repeat the scan annually and see if anything new pops up, and work it up a bit if it does. Expensive and time consuming, sure, but it beats ending up in palliative care riddled with mets.

That's the way I see it. What about yall?

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[Podstar]

Or all of the radiation from repeated full body CTs gives you cancer.

 

[Booze Aldrin]

I'd definitely go the MRI route. I only put the low dose CT in there as an option for those who don't want to spend a few grand a pop for the MRI but yeah, I'd not advise it.

 

[Gurby]

"Seems reasonable", I think to myself as I eat a giant bowl of ice cream...

 

[CharlieBillings]

.

 

[NotAProgDirector]

It's a terrible idea. You're certain to find all sorts of small incidental issues. You already have an unreasonable anxiety about cancer, your suggestion that you'd "hold the gun on chasing incidental findings unless they're markedly worrisome or clinically corroborated." isn't the way things will go. These findings will eat at you, and increase your worry. And the cancers that young people rarely get tend to grow and metastatize quickly, such that an annual screen isn't likely to be helpful. Even in high risk individuals (smokers and lung cancer), annual screening makes a very small difference -- in low risk like yourself it will make no difference.

 

[Angus Avagadro]

Check into it, but outpatient out of pocket cancer screening centers have been around for awhile

 

[jdh71]

No. I don’t think of doing that.

 

[Booze Aldrin]

It's a terrible idea. You're certain to find all sorts of small incidental issues. You already have an unreasonable anxiety about cancer, your suggestion that you'd "hold the gun on chasing incidental findings unless they're markedly worrisome or clinically corroborated." isn't the way things will go. These findings will eat at you, and increase your worry.

I wouldn't say my anxiety about cancer is unreasonable. I think looking into potential ways to minimize my chances of dying of an agonizing and extremely common health issue is fairly reasonable. At any rate, the above is a claim you are making about my psychology rather than the merits of whole body screening. If I were to go down the rabbit hole of chasing incidental findings discovered on the first scan despite my initial expressed intention not to do so, then that would be a shortcoming on the part of my personality, not a defect of the screening approach itself. Might as well say that trying to quite drinking or lose weight is a terrible idea because you'll never follow through with it anyway ya bum! lol.

And the cancers that young people rarely get tend to grow and metastatize quickly, such that an annual screen isn't likely to be helpful. Even in high risk individuals (smokers and lung cancer), annual screening makes a very small difference -- in low risk like yourself it will make no difference.

That is a much more valid concern, and indeed one of the areas I would need to do a lot more research into if I were ever to take this whole body scan idea from the idle thinking stage into the execution stage. Some of the things I'd like to figure out:

What are the odds of getting a "random" cancer outside of the big boys like colon, lung, prostate, skin (which have their own dedicated screens not requiring whole body MRI) for a given decade of life in a male non smoker with no family history of cancer?

How long does it typically take for those "random" cancers to become invasive and metastatic after they are large enough to be seen on imaging? If the typical "random" cancer becomes un-resectable an average of 2 months after being large enough to be seen on MRI, then clearly annual MRI screens would be completely pointless unless your plan is simply to be lucky.

I'm 4 years away from being an attending so it's not like I'm about to call a MRI in the box to schedule an appointment. Making this thread was a first step of doing due diligence into this idea. I'll do a lot more digging and if it proves to be impractical or useless I'll certainly drop it before I spend a dollar.

 

[VA Hopeful Dr]

If whole body cancer scans were worth it, there would be evidence out there about it.

There isn't because they're not.

Even the data behind the cancer screens we have often sucks (looking at you prostate).

 

[Ho0v-man]

Sounds like your gonna do it regardless of what anyone says.

So it’s really just cheaper if you have good insurance and privileges at a hospital that just doesn’t charge doctors for anything to go to the ER and fake a head ache and belly pain. BOOM—> donut of truth!

Next week complain of cp and stub your toe in the lobby so you can elevate your d-dimer
BOOM—> give yourself lung cancer to r/o lung cancer.

Fake some neck pain and radiculopathy—>mri csp.

Unethical? Yes. Cheap? YES!

 

[Ho0v-man]

All joking aside, when we got our new CT scanner at an old job and they needed to set up protocols for coronary CTA; the docs on staff were lining up to be guinea pigs for the free screening.

One of them ended up going straight to the cath lab.

 

[Tenk]

I plan to buy MRIs every 5 to 10 years once I hit my 40s for this very reason. Why? Cause I can afford it. The reason we don’t do it for the general population is because it is not cost effective. Ct though? Hell no.

Also keep in mind anything you pay for with insurance can be traced by insurance companies which can affect your ability/rates to get life and disability insurance. Pay in cash under the table at a closed clinic and nobody knows.

 

[CharlieBillings]

.

 

[Tenk]

You're saying you would speak to an insurance company about life insurance and it would go like:

Insurance: Do you have any terminal conditions?

You: Not that I know of.

Insurance: Do you have any reason to believe you have serious health conditions? Including recent abnormal physical exams, lab values, imaging, or other?

You: Well my doctor said I am fine, but I self paid for an MRI and there was this little unknown lesion in my abdomen....

Insurance: Get a full workup or you're denied.

You: That would mean I need a biopsy which has some level of risk.

Insurance: Get it or you're denied.

When you apply for life and disability insurance as a high paying professional (these policies are in the millions) they get ahold of all your records. If you deny them they just say we won't cover you as they don't have to. They may also do some blood tests and a screening EKG, never heard of imaging but wouldn't surprise me if the policy was high enough. If you've had an MRI done covered by insurance and it showed pancreatic cancer and you didn't have life or disability insurance, guess what, you aren't getting any. If you did it at an outside source with cash without a paper trail, you could definitely sneak in under the radar then complain of abdominal pain and get your treatment covered by insurance while keeping your existing policies.

Also: **** insurance companies. I hate them.

 

[Cognovi]

Screening imaging can be easily proven to detect many cancers with good performance characteristics (though costly), but early detection (while asymptomatic rather than coming to clinical attention via symptoms) does not necessarily mean prolonged survival.

 

[libertyyne]

Unless you have a family history of a cancer syndrome this is the single best way to die Young of iatrogenic complications of all the pointless procedures you are going to have done as a result of this .

Live life the best you can, don't over induldge, avoid carinogens, and seek care when you need to. And let the chips fall where they may. You might die of a car accident or a tornado tomorrow. Making all of this futuile.

 

[CJhooper123]

[Edit- mostly talking about MRI here]

Anybody else thinking of doing this once you have those (hopefully) big fat attending paychecks? I'm not going to lie, after months of inpatient medicine cancer has really began to freak me out and the thought of just passively waiting and hoping I never get it doesn't sit right with me.

It's definitely not something to feasibly implement on the societal level, but it's perfectly feasible on a self-funded basis by motivated individuals. You do your initial scan to establish the baseline and hold the gun on chasing incidental findings unless they're markedly worrisome or clinically corroborated. Odds are anything you find on a first scan in your 30's has probably been there for a minute and isn't going to cause you any trouble. Then you just repeat the scan annually and see if anything new pops up, and work it up a bit if it does. Expensive and time consuming, sure, but it beats ending up in palliative care riddled with mets.

That's the way I see it. What about yall?

I've always thought about doing this when older... but nahh. Too much anxiety. I'm putting that money in a travel fund. Get busy living son... otherwise your dying.

 

[CherryRedDracul]

I'm for it. More negative scans = more easy RVUs.

 

[MSTP18]

I'm for it. More negative scans = more easy RVUs.

I guess I'm ok with it. More "incidentalomas" means more biopsies for me! And as the pathologist I have the added benefit of never having to deal with the patient or their family when they have a negative complication from an unnecessary biopsy!

 

[Booze Aldrin]

I plan to buy MRIs every 5 to 10 years once I hit my 40s for this very reason. Why? Cause I can afford it. The reason we don’t do it for the general population is because it is not cost effective. Ct though? Hell no.

Also keep in mind anything you pay for with insurance can be traced by insurance companies which can affect your ability/rates to get life and disability insurance. Pay in cash under the table at a closed clinic and nobody knows.

Isn't every 5 years too long of an interval? I honestly have no idea, figuring out how quickly tumors stage is one of the fundamental questions I'd have to answer before I decided on whether to do scanning and how frequently.

 

[ortnakas]

Isn't every 5 years too long of an interval? I honestly have no idea, figuring out how quickly tumors stage is one of the fundamental questions I'd have to answer before I decided on whether to do scanning and how frequently.

This is kind of the problem with your plan in general. There’s no data on how often full body scans should be done because generally fishing expeditions are a bad idea (vs risk-factor based, guideline based testing)

 

[TelemarketingEnigma]

If I were to go down the rabbit hole of chasing incidental findings discovered on the first scan despite my initial expressed intention not to do so, then that would be a shortcoming on the part of my personality, not a defect of the screening approach itself.

A screening approach is only effective if it works in a real world context, which includes dealing with "shortcomings" in personality. In the real world, most humans are irrational and anxious to some degree. Despite the best of intentions before receiving a finding, most people don't know how they would respond to an incidental finding until after they receive it - and for many people, they will experience some degree of anxiety, which leads to followup that is unnecessary for (and possibly detrimental to) their physical health, but becomes necessary in order to calm their anxiety about the incidental finding... I wouldn't call any of this a personality "shortcoming," just human nature.

 

[MedicineZ0Z]

If whole body cancer scans were worth it, there would be evidence out there about it.

There isn't because they're not.

Even the data behind the cancer screens we have often sucks (looking at you prostate).

Prostate biopsy complication rates are overrated if done by a competent urologist. You can track PSA and use other scoring systems to help you guide the need for a biopsy.
The whole "don't screen" thing led to more prostate cancer mets.


The issue with the whole screening/false positive etc thing is that it removes good clinical judgement from the equation. How good is the person investigating? And lets not forget those who write guidelines aren't responsible for the patients.

 

[ortnakas]

The issue with the whole screening/false positive etc thing is that it removes good clinical judgement from the equation. How good is the person investigating? And lets not forget those who write guidelines aren't responsible for the patients.

Pan-scanning on a regular basis without an indication (be it an evidence-based guideline or a sign/symptom/lab) also removes clinical judgement from the equation.

 

[VA Hopeful Dr]

Prostate biopsy complication rates are overrated if done by a competent urologist. You can track PSA and use other scoring systems to help you guide the need for a biopsy.
The whole "don't screen" thing led to more prostate cancer mets.


The issue with the whole screening/false positive etc thing is that it removes good clinical judgement from the equation. How good is the person investigating? And lets not forget those who write guidelines aren't responsible for the patients.

Did it alter survival rates? Also, does everyone have access to a competent urologist?

Because aggressive PSA testing didn't change prostate cancer death rate per capita...

 

[Dro133]

Did it alter survival rates? Also, does everyone have access to a competent urologist?

Because aggressive PSA testing didn't change prostate cancer death rate per capita...

No difference in all-cause mortality between screened and unscreened groups. There may be some small benefit in African American patients and those with a history of prostate cancer, but the results are inconclusive. Definitely nothing to suggest that prostate cancer screening leads to more benefit than harm...

Sauce

 

[VA Hopeful Dr]

No difference in all-cause mortality between screened and unscreened groups. There may be some small benefit in African American patients and those with a history of prostate cancer, but the results are inconclusive. Definitely nothing to suggest that prostate cancer screening leads to more benefit than harm...

Sauce

I'm well aware, I was seeing if our pro-PSA colleague knew the data

 

[MedicineZ0Z]

Pan-scanning on a regular basis without an indication (be it an evidence-based guideline or a sign/symptom/lab) also removes clinical judgement from the equation.

No i wasn't advocating for pan scanning.

Did it alter survival rates? Also, does everyone have access to a competent urologist?

Because aggressive PSA testing didn't change prostate cancer death rate per capita...

How do you take data over thousands of patients and apply it to a 58 year old male with prostate cancer mets who could have been treated earlier? And who was very healthy otherwise.
Large sets of data do not apply to individual patients in a direct fashion cause they ignore the ones who get screwed.

 

[Dro133]

How do you take data over thousands of patients and apply it to a 58 year old male with prostate cancer mets who could have been treated earlier? And who was very healthy otherwise.
Large sets of data do not apply to individual patients in a direct fashion cause they ignore the ones who get screwed.

Sure, but what about the patients who are diagnosed with prostate cancer and undergo invasive procedures with possible complications for a disease they never would have died from anyways? That's the point of population-based screening, to minimize the harms to society as a whole. That said, this doesn't mean no one should be screened; even though the USPSTF generally recommends against prostate cancer screening, they say "the decision about whether to be screened for prostate cancer requires that each man incorporate his own values about the potential benefits and harms". Ultimately, the goal should be to find better ways to stratify patients based on their risk factors, so that we can work together with patients to make better informed decisions about screening; however, given the current data, in the absence of risk factors, there's no evidence that screening everyone for prostate cancer leads to a net overall benefit.

 

[VA Hopeful Dr]

No i wasn't advocating for pan scanning.


How do you take data over thousands of patients and apply it to a 58 year old male with prostate cancer mets who could have been treated earlier? And who was very healthy otherwise.
Large sets of data do not apply to individual patients in a direct fashion cause they ignore the ones who get screwed.

That's the thing, the data doesn't say that guy could have been saved with PSA screening.

 

[Dro133]

That's the thing, the data doesn't say that guy could have been saved with PSA screening.

Well, to be fair, a regular PSA screen may very well have detected that individual patient's prostate cancer before it metastasized. The problem is that in order to save that one man's life, 17 other patients (NNT of 18) who would have ultimately died from causes other than their cancer would have undergone unnecessary treatment, along with all the possible treatment complications, psychological ramifications, cost to society, etc. that may come with it.

 

[DoctwoB]

Did it alter survival rates? Also, does everyone have access to a competent urologist?

Because aggressive PSA testing didn't change prostate cancer death rate per capita...

That is categorically false.

A 16-yr Follow-up of the European Randomized study of Screening for Prostate Cancer - PubMed

In this report, we looked at the outcomes from prostate cancer in a large European population. We found that repeated screening reduces the risk of dying from prostate cancer.

www.ncbi.nlm.nih.gov

For every 570 men you offer PSA screening (note some decline) you save one life. Number needed to diagnose (note not treat) was 18. Note that the number needed to screen to prevent one death is lower then in colon ca (1250) or in breast (781) and mammograms and colonoscopies are more invasive and expensive then PSAs.

Screening and the number needed to treat - PubMed

The NNT calculations may make population based screening programmes seem expensive and inefficient compared with other interventions. A new measure, the number needed to be screened (NNBS), which takes into account the participation rate adjusted for selection, may be more appropriate...

www.ncbi.nlm.nih.gov

 

[DoctwoB]

Well, to be fair, a regular PSA screen may very well have detected that individual patient's prostate cancer before it metastasized. The problem is that in order to save that one man's life, 17 other patients (NNT of 18) who would have ultimately died from causes other than their cancer would have undergone unnecessary treatment, along with all the possible treatment complications, psychological ramifications, cost to society, etc. that may come with it.

You are correct the NN (to diagnose, not necessarily treat) was 18 to prevent one death. However the NND to prevent one case of metastatic disease (likely to become death with longer follow up) was closer to 7.

Also, many of those other patients who underwent treatment but weren’t “saved” doesn’t mean treatment was unnecessary or not beneficial. Maybe they still died of prostate cancer but earlier treatment extended their life or prevented local progression (a nightmare in prostate ca). Maybe they died suddenly from a MI/PE/car crash instead of slowly from cancer. The NNT to prevent one death doesn’t tell the whole story.

 

[Dro133]

That is categorically false.

A 16-yr Follow-up of the European Randomized study of Screening for Prostate Cancer - PubMed

In this report, we looked at the outcomes from prostate cancer in a large European population. We found that repeated screening reduces the risk of dying from prostate cancer.

www.ncbi.nlm.nih.gov

For every 570 men you offer PSA screening (note some decline) you save one life. Number needed to diagnose (note not treat) was 18. Note that the number needed to screen to prevent one death is lower then in colon ca (1250) or in breast (781) and mammograms and colonoscopies are more invasive and expensive then PSAs.

Screening and the number needed to treat - PubMed

The NNT calculations may make population based screening programmes seem expensive and inefficient compared with other interventions. A new measure, the number needed to be screened (NNBS), which takes into account the participation rate adjusted for selection, may be more appropriate...

www.ncbi.nlm.nih.gov

The numbers you quote aren't entirely fair, as the follow-up time in the prostate cancer study was twice as long (16 yrs) as the breast and colon cancer study (8 yrs). At 9 year follow-up, the NNS for PSA screening was higher (1,410) than both breast and colon.

 

[Dro133]

You are correct the NN (to diagnose, not necessarily treat) was 18 to prevent one death. However the NND to prevent one case of metastatic disease (likely to become death with longer follow up) was closer to 7.

Also, many of those other patients who underwent treatment but weren’t “saved” doesn’t mean treatment was unnecessary or not beneficial. Maybe they still died of prostate cancer but earlier treatment extended their life or prevented local progression (a nightmare in prostate ca). Maybe they died suddenly from a MI/PE/car crash instead of slowly from cancer. The NNT to prevent one death doesn’t tell the whole story.

All fair points. Do you have a source that the NNT was closer to 7? Unless I missed it in the article you posted.

Ultimately, what it comes down to for me is what NNT/NND (or other endpoint that maybe more successfully captures true benefit) makes screening "worth it"? Is it 5? Is it 10? 20? And are there any other statistical endpoints other than NNT/NND that can help us better capture the true benefit of an intervention?

 

[MedicineZ0Z]

Playing with all the data and studies is great, but I still don't see how it helps a relatively younger patient who is very healthy but has bad luck. Someone who can live to 90 but develops prostate cancer at 50 can be saved if the right screening was done.

Yes the data shows you need to screen X people to catch Y cases but there's no reason you need to send off every borderline screening test for more invasive testing. It's like ECGs. If you can read them properly, you won't be echoing every "abnormal" ekg like the guidelines suggest happens.

Clinical judgement and competency is key. We shouldn't be guideline robots.

 

[CherryRedDracul]

I guess I'm ok with it. More "incidentalomas" means more biopsies for me! And as the pathologist I have the added benefit of never having to deal with the patient or their family when they have a negative complication from an unnecessary biopsy!

Unfortunately, I have to deal with the complications. Not too long ago during an outpatient lung nodule biopsy, I dropped a patient's lung and had to throw in a chest tube as an added bonus. We sent him for observation, but his lung still wasn't coming up, so we unfortunately had to admit him (the CT surgery service graciously accepted him as they were the referrers). He had developed a persistent air leak.

 

[DoctwoB]

The numbers you quote aren't entirely fair, as the follow-up time in the prostate cancer study was twice as long (16 yrs) as the breast and colon cancer study (8 yrs). At 9 year follow-up, the NNS for PSA screening was higher (1,410) than both breast and colon.

True, though the natural history of prostate cancer definitely requires longer follow up then breast or colon. I don’t know how much more the breast or colon data would improve with longer follow up (outside my area).

 

[DoctwoB]

All fair points. Do you have a source that the NNT was closer to 7? Unless I missed it in the article you posted.

Ultimately, what it comes down to for me is what NNT/NND (or other endpoint that maybe more successfully captures true benefit) makes screening "worth it"? Is it 5? Is it 10? 20? And are there any other statistical endpoints other than NNT/NND that can help us better capture the true benefit of an intervention?

The NND to prevent one case of metastatic disease was not reported in the latest ERSPC update, but an analysis of the 13 year data showed the reduction in metastatic disease was 3fold greater then the reduction in mortality. Whether that also continues to improves with increased follow up remains to be seen, or at least I haven’t seen that data.

Metastatic Prostate Cancer Incidence and Prostate-specific Antigen Testing: New Insights from the European Randomized Study of Screening for Prostate Cancer - PubMed

The findings of this study indicate that the decrease in metastatic disease at diagnosis is the major determinant of the prostate cancer mortality reduction in the European Randomized study of Screening for Prostate Cancer.

www.ncbi.nlm.nih.gov

Also note the prostate mortality numbers will continue to improve with longer follow up? Why? Because while there is 16 year data from randomization, median follow up from prostate Ca diagnosis is 8 years. And a majority of prostate Ca deaths occur after that time frame. In fact, in the first ERSPC trial center with 19 year data, the NNS to prevent one death was down to 101, with a NND of 3. Hard to argue with that data.

Results of Prostate Cancer Screening in a Unique Cohort at 19 yr of Follow-up

We assessed the effect of screening in the European Randomized study of Screening for Prostate Cancer (ERSPC) Rotterdam pilot 1 study cohort with men …

www.sciencedirect.com

 

[VA Hopeful Dr]

That is categorically false.

A 16-yr Follow-up of the European Randomized study of Screening for Prostate Cancer - PubMed

In this report, we looked at the outcomes from prostate cancer in a large European population. We found that repeated screening reduces the risk of dying from prostate cancer.

www.ncbi.nlm.nih.gov

For every 570 men you offer PSA screening (note some decline) you save one life. Number needed to diagnose (note not treat) was 18. Note that the number needed to screen to prevent one death is lower then in colon ca (1250) or in breast (781) and mammograms and colonoscopies are more invasive and expensive then PSAs.

Screening and the number needed to treat - PubMed

The NNT calculations may make population based screening programmes seem expensive and inefficient compared with other interventions. A new measure, the number needed to be screened (NNBS), which takes into account the participation rate adjusted for selection, may be more appropriate...

www.ncbi.nlm.nih.gov

Umm, is it though? The USPSTF has this to say:

"Across all ERSPC sites, prostate cancer mortality was statistically significantly reduced only at the sites in the Netherlands and Sweden "

But let's assume for the sake of argument that you're correct. The people who ran this trial had this to say:

Greater absolute benefit from PSA screening at 13 years of follow-up in the ERSPC trial not sufficient to justify population-based screening - ERSPC

The third analysis on prostate cancer mortality in the ERSPC trial, published in the Lancet August 2014, shows stable relative (RR=0.79) but larger absolute benefit in follow-up extended to 13 years (two additional years from the previous report). The ERSPC is the largest randomized trial of...

www.erspc.org

 

[DoctwoB]

Umm, is it though? The USPSTF has this to say:

"Across all ERSPC sites, prostate cancer mortality was statistically significantly reduced only at the sites in the Netherlands and Sweden "

But let's assume for the sake of argument that you're correct. The people who ran this trial had this to say:

Greater absolute benefit from PSA screening at 13 years of follow-up in the ERSPC trial not sufficient to justify population-based screening - ERSPC

The third analysis on prostate cancer mortality in the ERSPC trial, published in the Lancet August 2014, shows stable relative (RR=0.79) but larger absolute benefit in follow-up extended to 13 years (two additional years from the previous report). The ERSPC is the largest randomized trial of...

www.erspc.org

That is the whole point of multi-center randomized trials, that it is difficult to show statistical significance in a screening population at a single center because the vast majority of the population won't even have the disease being screened for. Demanding not only that the whole population show a statistically significant benefit, but that each subpopulation and enrolling center show a statistically significant benefit defeats the entire purpose of the study design. Furthermore, the sites that did show the most benefit were not surprisingly the sites that had the least contamination (PSA testing in the control arm). It's hard to show a benefit to intervention when the control arm also gets the intervention at a reasonably high rate. Note this is also why the PLCO trial (a US PSA screening trial) that the USPSTF partially based their grade D PSA screening recommendation on, actually had more PSA testing done in the control arm then in the intervention arm in addition to having an enrolled population that had 40% of patients with prior PSA tests (aka pre-screened)

In non intention to treat analysis, i.e. based on who actually received PSA screening in the ERSPC trial,, the benefit of PSA screening was even higher, with a prostate cancer mortality reduction of closer to 50% instead of 30% (at 13 year, not 16 year data)

Prostate-specific antigen-based prostate cancer screening: reduction of prostate cancer mortality after correction for nonattendance and contamination in the Rotterdam section of the European Randomized Study of Screening for Prostate Cancer - PubMed

ISRCTN49127736.

www.ncbi.nlm.nih.gov

As to the last point about population based screening, that is a matter for debate. As others have mentioned in this thread, what is the cutoff point to say we should screen a population? How many excess biopsies and unnecessary cancer dx outweigh saving one life? The short answer is that there is no good answer to that question. Ideally it would be an individual decision, but to expect a PCP to accurately describe the pros and cons of PSA screening to each patient in a way that accurately reflects the data in the setting of all the other problems they need to deal with is not a reasonable request IMO. I tend to recommend that PCPs screen, and then what to do with the PSA level can and should be an individual decision. I can spend 20 minutes specifically discussing the meaning of the PSA result with the patient, something PCPs can't afford to do. There are plenty of 70 years olds with a PSA of 5 that I tell not to biopsy, and many 50 years olds with a PSA of 2.5 that I would recommend biopsy for. But without a PSA its a moot point.

To that end though, since the ERSPC trial we have new tools in our pocket. Using prostate MRI to triage patients before prostate biopsy can increase detection of clinically significant prostate cancer, reduce detection of low risk prostate cancer, and reduce biopsies by about 30% based on level 1 evidence. This is rapidly becoming standard of care. That means that even compared to the compelling ERSPC data, we can now screen with greater benefit at lower risk.

 

[VA Hopeful Dr]

That is the whole point of multi-center randomized trials, that it is difficult to show statistical significance in a screening population at a single center because the vast majority of the population won't even have the disease being screened for. Demanding not only that the whole population show a statistically significant benefit, but that each subpopulation and enrolling center show a statistically significant benefit defeats the entire purpose of the study design. Furthermore, the sites that did show the most benefit were not surprisingly the sites that had the least contamination (PSA testing in the control arm). It's hard to show a benefit to intervention when the control arm also gets the intervention at a reasonably high rate. Note this is also why the PLCO trial (a US PSA screening trial) that the USPSTF partially based their grade D PSA screening recommendation on, actually had more PSA testing done in the control arm then in the intervention arm in addition to having an enrolled population that had 40% of patients with prior PSA tests (aka pre-screened)

In non intention to treat analysis, i.e. based on who actually received PSA screening in the ERSPC trial,, the benefit of PSA screening was even higher, with a prostate cancer mortality reduction of closer to 50% instead of 30% (at 13 year, not 16 year data)

Prostate-specific antigen-based prostate cancer screening: reduction of prostate cancer mortality after correction for nonattendance and contamination in the Rotterdam section of the European Randomized Study of Screening for Prostate Cancer - PubMed

ISRCTN49127736.

www.ncbi.nlm.nih.gov

As to the last point about population based screening, that is a matter for debate. As others have mentioned in this thread, what is the cutoff point to say we should screen a population? How many excess biopsies and unnecessary cancer dx outweigh saving one life? The short answer is that there is no good answer to that question. Ideally it would be an individual decision, but to expect a PCP to accurately describe the pros and cons of PSA screening to each patient in a way that accurately reflects the data in the setting of all the other problems they need to deal with is not a reasonable request IMO. I tend to recommend that PCPs screen, and then what to do with the PSA level can and should be an individual decision. I can spend 20 minutes specifically discussing the meaning of the PSA result with the patient, something PCPs can't afford to do. There are plenty of 70 years olds with a PSA of 5 that I tell not to biopsy, and many 50 years olds with a PSA of 2.5 that I would recommend biopsy for. But without a PSA its a moot point.

To that end though, since the ERSPC trial we have new tools in our pocket. Using prostate MRI to triage patients before prostate biopsy can increase detection of clinically significant prostate cancer, reduce detection of low risk prostate cancer, and reduce biopsies by about 30% based on level 1 evidence. This is rapidly becoming standard of care. That means that even compared to the compelling ERSPC data, we can now screen with greater benefit at lower risk.

If true then I would bet the guidelines change the next time they get looked at.

 

[MSTP18]

Prostate biopsy complication rates are overrated if done by a competent urologist. You can track PSA and use other scoring systems to help you guide the need for a biopsy.
The whole "don't screen" thing led to more prostate cancer mets.


The issue with the whole screening/false positive etc thing is that it removes good clinical judgement from the equation. How good is the person investigating? And lets not forget those who write guidelines aren't responsible for the patients.

The most competent urologists are still sticking a needle through your ****laden rectum into your prostate and potentially seeding it with bacteria that aren't supposed to be there..

 

[MedicineZ0Z]

The most competent urologists are still sticking a needle through your ****laden rectum into your prostate and potentially seeding it with bacteria that aren't supposed to be there..

And the complication rates in literature include or exclude residents/fellows?

 

[MSTP18]

And the complication rates in literature include or exclude residents/fellows?

Does your prostate react differently to the E. Faecalis injection if it knows an attending did it instead of a resident/fellow?

 

[DoctwoB]

The most competent urologists are still sticking a needle through your ****laden rectum into your prostate and potentially seeding it with bacteria that aren't supposed to be there..

Post prostate biopsy infections are a real issue, regardless of technical skill. Most studies find rates of .5-2%, so a small, but not insignificant risk. The risk can be lowered through augmented antibiotic prophylaxis, transperineal approach, sterilizing the needle between each pass, etc but not brought to 0.

Fortunately, even though patients can get sick from these Infections, basically the source is transient inoculation from the needle stick, so basically they already have source control on presentation, and they respond very well to abx and supportive care, the the rate of long term sequalae is extremely low.

 

[whoknows2012]

This PSA talk is infuriating. The whole point of the USPSTF guideline saying it should be a discussion with the patient on an individualized basis takes into account that the data is not entirely clear. If it was clear then we would continue screening with PSA like we did a decade ago. And for the talk about the 50 year old that could’ve been saved with the PSA screen?

A) no guarantee they could be saved. Screening interval and biologic behavior of the prostate cancer would dictate that-and a younger man who gets prostate cancer could definitely be on the more aggressive end

B) as others have said, how many are harmed? You can’t, as a urologist, say “in my hands, all prostate biopsies go smoothly.” That’s stilly. This is POPULATION wide screening. Not screening for the patients that end up in your office only.

C) I agree it is easy to screen for prostate cancer. The cost, harms and lack of CLEAR survival benefit make it a fools errand to try and argue we should screen at a population level. I also find it particularly interesting that it was suggested that PCPs leave the “discussion” about what to do with a positive screen to the urologist and just screen everyone. Like a damn robot.