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Article of the week: ‘Dr Google’: trends in online interest in prostate cancer screening, diagnosis and treatment

Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an editorial and a visual abstract written by prominent members of the urological community. These are intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation. 

If you only have time to read one article this month, it should be this one.

‘Dr Google’: trends in online interest in prostate cancer screening, diagnosis and treatment

Michael E. Rezaee*, Briana Goddard, Einar F. Sverrisson*, John D. Seigne* and Lawrence M. Dagrosa*

*Section of Urology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, and Geisel School of Medicine, Hanover

Abstract

Objectives

To examine trends in online search behaviours related to prostate cancer on a national and regional scale using a dominant major search engine.

Materials and Methods

Google Trends was queried using the terms ‘prostate cancer’, ‘prostate‐specific antigen’ (PSA), and ‘prostate biopsy’ between January 2004 and January 2019. Search volume index (SVI), a measure of relative search volume on Google, was obtained for all terms and examined by region and time period: pre‐US Preventive Services Task Force (USPSTF) Grade D draft recommendation on PSA screening; during the active Grade D recommendation; and after publication of the recent Grade C draft recommendation.

Results

Online interest in PSA screening differed by time period (P < 0.01). The SVI for PSA screening was greater pre‐Grade D draft recommendation (82.7) compared to during the recommendation (74.5), while the SVI for PSA screening was higher post‐Grade C draft recommendation (90.4) compared to both prior time periods. Similar results were observed for prostate biopsy and prostate cancer searches. At the US state level, online interest in prostate cancer was highest in South Carolina (SVI 100) and lowest in Hawaii (SVI 64). For prostate cancer treatment options, online interest in cryotherapy, prostatectomy and prostate cancer surgery overall increased, while searches for active surveillance, external beam radiation, brachytherapy and high‐intensity focused ultrasonography remained stable.

Conclusion

Online interest in prostate cancer has changed over time, particularly in accordance with USPSTF screening guidelines. Google Trends may be a useful tool in tracking public interest in prostate cancer screening, diagnosis and treatment, especially as it relates to major shifts in practice guidelines.

Editorial: Does Dr Google give good advice about prostate cancer?

In this issue of BJUI, Rezaee et al. [1] report on Google trends as a barometer of public interest in PSA screening and different types of prostate cancer treatment in the USA. Not surprisingly, they found a decrease in Google searches about PSA screening after the US Preventive Services Task Force (USPSTF) issued a Grade D recommendation against screening. This corresponds with observed trends of decreased PSA screening in the population [2]. Notably, the volume of Google searches about PSA screening rebounded after the USPSTF changed to a Grade C recommendation for shared decision-making about screening. It is unknown whether this actually reflects a greater number of men discussing PSA screening with their doctors, or whether online information had an impact on their decisions.

Meanwhile, the quantity of Google search activity varied between different types of prostate cancer treatment. In the USA, search volume was higher for surgery than for active surveillance, and there was a greater search volume for high intensity focused ultrasonography (HIFU) than for external beam radiation therapy or brachytherapy. Notably, another recent study examined global Google trends in searches on prostate cancer treatment, showing increasing annual relative search volume for focal therapy and active surveillance over time [3]. The underlying reasons for these temporal and geographic differences in ‘public interest’ may be multifactorial, including recommendations from physicians and professional societies, support from policy-makers, public awareness campaigns from healthcare-related organizations and marketing from commercial companies. Whether the change in ‘public interest’ had any impact on treatment selection remains unknown.

As an increasing number of people are going online for health information, digital platforms provide useful barometers for public interest in different topics. For example, another recent study reported that prostate cancer was a topic with high public interest based on the number of video views on YouTube compared to other urological conditions [4]. While interesting, the number of Google searches or views on YouTube do not provide any insights into who is searching for the information, their motivation, and the quality of information that they received.

Concerningly, several recent studies have called into question the accuracy of information about prostate cancer across multiple online platforms. Asafu-Adjei et al. [5] reported that websites on HIFU and cryotherapy had a substantial amount of incomplete or inaccurate information. Alsyouf et al. [6] reported that seven of the 10 most commonly shared articles about prostate cancer on social media were inaccurate or misleading. Finally, our group reported that 77% of the first 150 YouTube videos about prostate cancer had potentially misinformative and/or biased content in the video itself or the comments underneath [7]. Alarmingly, the quality of information was inversely correlated with the number of views. More research is needed to evaluate the impact of exposure to online misinformation on prostate cancer screening and treatment.

Overall, the online environment holds great promise and also great peril in prostate cancer. On one hand, digital networks have opened up new opportunities for global scientific exchange and have the potential to greatly improve patient care. Conversely, there is a substantial amount of misinformation on the internet, and the potential for a negative impact on patients and their families. As a urological community, we should be pro-active about directing our patients to trustworthy online resources, and should actively participate in digital networks to help share high-quality information with the public. More strategic effort should also be made to maximize the degree of reach and engagement upon dissemination of high-quality information.

by Stacy Loeb, Nataliya Byrne and Jeremy Teoh

References

  1. Rezaee ME, Goddard B, Sverrisson EF, Seigne JD, Dagrosa LM. ‘Dr Google’: trends in online interest in prostate cancer screening, diagnosis and treatment. BJU Int 2019; 124: 629–34
  2. Magnani CJ, Li K, Seto T et al. PSA Testing Use and Prostate Cancer Diagnostic Stage After the 2012 U.S. Preventive Services Task Force Guideline Changes. JNCCN 2019; 17: 795–803
  3. Cacciamani GE, Bassi S, Sebben M et al. Consulting “Dr. Google” for prostate cancer treatment options. A contemporary worldwide trend analysis. Eur Urol Oncol 2019; https://doi.org/10.1016/j.euo.2019.07.002
  4. Borgmann H, Salem J, Baunacke M et al. Mapping the landscape of urology: a new media-based cross-sectional analysis of public versus academic interest. Int J Urol 2018; 25: 421–8
  5. Asafu-Adjei D, Mikkilineni N, Sebesta E, Hyams E. Misinformation on the Internet regarding Ablative Therapies for Prostate Cancer. Urology 2019; https://doi.org/10.1016/j.urology.2018.12.050
  6. Alsyouf M, Stokes P, Hur D, Amasyali A, Ruckle H, Hu B. ‘Fake News’ in urology: evaluating the accuracy of articles shared on social media in genitourinary malignancies. BJU Int 2019; 124: 701–6
  7. Loeb S, Sengupta S, Butaney M et al. Dissemination of Misinformative and Biased Information about Prostate Cancer on YouTube. Eur Urol 2019; 27: 564–7

 

West Coast Urology: Highlights from the AUA 2016 in San Diego… Part 2

By Ben Challacombe (@benchallacombe) and Jonathan Makanjuola (@jonmakurology)

 

The AUA meeting was starting to hot up with the anticipation of the Crossfire sessions, PSA screening and the MET debate that appeared to rumble on.  We attended the MUSIC (Michigan Urological Surgery Improvement Collaborative) session. It is a fantastic physician led program including >200 urologists, which aims to improve the quality of care for men with urological diseases. It is a forum for urologists across Michigan, USA to come together to collect clinical data, share best practices and implement evidence based quality improvement activities. One of their projects is crowd reviewing of RALP by international experts for quality of the nerve spare in order to improve surgical outcomes.

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The MET debate continues to cause controversy. In the UK there has been almost uniform abandonment of the use of tamsulosin for ureteric stones following The Lancet SUSPEND RCT.

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The MET crossfire debate was eagerly awaited. The debate was led by James N’Dow (@NDowJames) arguing against and Philipp Dahm (@EBMUrology) in favour of MET. Many have criticised the SUSPEND paper for lack of CT confirmation of stone passage. Dr Matlaga (@BrianMatlaga) stated that comparing previous studies of MET to SUSPEND is like comparing apples to oranges due to different outcome measures. He recommended urologists continue MET until more data is published. More conflicting statements were made suggesting that MET is effective in all patients especially for large stones in the ureter. The AUA guidelines update was released and stated that MET can be offered for distal ureteric stones less than 10mm.

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In a packed Endourology video session there were many high quality video presentations. One such video was a demonstration of the robotic management for a missed JJ ureteric stent. Khurshid Ghani (@peepeeDoctor) presented a video demonstrating the pop-corning and pop-dusting technique with a 100w laser machine.

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One of the highlights of the Sunday was the panel discussion plenary session, Screening for Prostate Cancer: Past, Present and Future. In a packed auditorium Stacy Loeb (@LoebStacy), gave an excellent overview of PSA screening with present techniques including phi, 4K and targeted biopsies. Freddie Hamdy looked into the crystal ball and gave a talk on future directions of PSA testing and three important research questions that still needed to be answered. Dr. Catalona presented the data on PSA screening and the impact of the PLCO trial. He argued that due to inaccurate reporting, national organisations should restore PSA screening as he felt it saved lives.

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There was a twitter competition for residents and fellows requiring participants to  tweet an answer to a previously tweeted question including the hashtag #scopesmart and #aua16. The prize was Apple Watch. Some of the questions asked included; who performed the 1st fURS? And what is the depth of penetration of the Holmium laser?

UK trainees picked up the prizes on the first two days.

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The British Association of Urological Surgeons (BAUS) / BJU International (BJUI) / Urological Society of Australia and New Zealand (USANZ) session was a real highlight of day three of the AUA meeting. There were high quality talks from opinion leaders in their sub specialities. Freddie Hamdy from Oxford University outlined early thoughts from the protecT study and the likely direction of travel for management of clinically localised prostate cancer. Prof Emberton (@EmbertonMark) summarised the current evidence for the role of MRI in prostate cancer diagnosis including his thoughts on the on going PROMIS trial. Hashim Ahmed was asked if HIFU was ready for the primetime and bought us up to speed with the latest evidence.

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The eagerly awaited RCT comparing open prostatectomy vs RALP by the Brisbane group was summarised with regards to study design and inclusion criteria. It is due for publication on the 18th May 2016 so there was a restriction of presenting results.  Dr Coughlin left the audience wanting more despite Prof. Dasgupta’s best effort to get a sneak preview of the results!  We learnt from BAUS president Mark Speakman (@Parabolics) about the UK effort to improve the quality of national outcomes database for a number of index urological procedures.

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Oliver Wiseman (@OJWiseman) gave us a flavour of outcomes from the BAUS national PCNL database and how they are trying drive up standards to improve patient care. A paediatric surgery update was given by Dr Gundeti. The outcomes of another trial comparing open vs laparoscopic vs RALP was presented. There was no difference in outcomes between the treatment modalities but Prof. Fydenburg summarised by saying that the surgeon was more important determinant of outcome than the tool. Stacy Loeb closed the meeting with an excellent overview of the use of twitter in Urology, followed by a drinks reception.

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It was not all about stones and robots. The results of the Refractory Overactive Bladder: Sacral NEuromodulation vs. BoTulinum Toxin Assessment (ROSETTA) trial results were presented. Botox came out on top against neuromodulation in urgency urinary incontinence episodes over 6 months, as well as other lower urinary tract symptoms.

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The late breaking abstract session presented by Stacy Loeb highlighted a paper suggesting a 56% reduction in high-grade prostate cancer for men on long term testosterone. This was a controversial abstract and generated a lot of discussion on social media.

 

 

 

 

 

 

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It has been an excellent meeting in San Diego and we caught up with old and met new friends. It was nice to meet urologists from across the globe with differing priorities and pressures. There was a good British, Irish and Australian contingent flying the flag for their respective countries. It was another record-breaking year for the #AUA16 on twitter. It surpassed the stats for #AUA15 with over 30M impressions, 16,659 tweets 2,377 participants. See you all in Boston for AUA 2017.

 

Where we are with screening and risk prediction for prostate cancer in 2016

March Editorial ImageThe rate of PSA-based screening over the last 35 years can be compared with driving your car from the Netherlands to Italy. It starts with a rather at drive, perhaps a few hills in the Southern part of the Netherlands, which represents the rate of PSA screening in the late 1980s. Moving with high speed through Germany, one gradually climbs to higher altitudes, i.e. the rate of PSA testing in the 1990s. Then the high (but very difcult to drive) summits and beautiful valleys of Switzerland are there, representing PSA testing practices in the new millennium and the decline in metastatic disease and related mortality [1]. Finally, we descend to Italys Po valley, comparable to PSA testing rates, especially in the USA after the recommendations of the USA Preventive Services Task Force [2,3].
The question is what will we do next? Will we take a left turn and slowly disappear into the sea like Venice? That is, returning to a situation where one out of two or three men died from their prostate cancer? [4] Or will we stop our car, look behind, see the beautiful landscape and return taking the Gotthard road tunnel, avoiding spillage of petrol (i.e. unnecessary PSA testing and potentially harmful prostate biopsies) and go straight to the valleys of Switzerland?
The rst option is obviously not the way to go. Unfortunately, the recommendation to stop the use of the PSA test as a screening tool is direct consequence of the rapid and uncontrolled uptake of the test, often followed by a random biopsy resulting in over-diagnosis and subsequent overtreatment. However, there are ample tools available to turn this situation around and reduce the negative effects of prostate cancer screening [5,6].
An example of such an approach can be found in the publication of Poyet et al. [7] in this issue of BJUI. In this study, the investigators validated updated versions of two multivariate risk-prediction tools, i.e. prostate cancer risk calculators (RCs), in a cohort of 1996 men all biopsied (6-, 8- or 12-core random biopsy) on the basis of an elevated PSA level or abnormal DRE. The data showed that both RCs outperformed the PSA/ DRE-based strategy in reducing unnecessary testing, and in addition avoided over-diagnosis. As said, this approach is one of the many opportunities to reduce the negative aspects of PSA-based screening all summarised in the different guidelines [8]. Reading these guidelines, it soon becomes clear that it is known that repeatedly testing men with low PSA levels is useless. It is known that screening men with a limited life expectancy will only cause harm, and that simply repeating a prostate biopsy after a negative biopsy result (i.e. no prostate cancer detected) is not the way to go. And yet, this is what we see happening in daily clinical practice [9,10].
So, where are we with prostate cancer screening and risk prediction in 2016? We are in a situation that we know that we can reduce suffering and death from (metastatic) prostate cancer, with early detection and treatment, but that we have to selectively identify men that can actually benet. The latter is realistic if we start to implement the knowledge we have acquired over recent decades.

 

Monique J. Roobol
Department of Urology, Erasmus University Medical Center, Rotterdam, The Netherlands

 

References

 

 

 

3 Banerji JS, Wolff EM, Massman JD 3rd, Odem-Davis K, Porter CR, Corman JMProstate Needle Biopsy Outcomes in the Era of the U.S. Preventive Services Task Force Recommendation against Prostate Specic Antigen Based Screening. J Urol 2016; 195: 6673

 

4 Hsing AW, Tsao L, Devesa SS. International trends and patterns of prostate cancer incidence and mortality. Int J Cancer 2000; 85: 607

 

5 Roobol MJ, Carlsson SV. Risk stratication in prostate cancer screening. Nat Rev Urol 2013; 10: 3848

 

 

 

8 Loeb S. Guideline of guidelines: prostate cancer screening. BJU Int 2014; 114: 3235

 

 

 

Correction: The word “their” was added to this sentence to clarify its meaning: “That is, returning to a situation where one out of two or three men died from their prostate cancer? [4]”

 

 

Does presentation with metastatic prostate cancer matter?

CaptureNovember saw the return of the International Urology Journal Club #urojc on Twitter. The annual meetings of the World Congress for Endourology (#WCE2015) and Société Internationale D’Urologie (#SIU15) led to an October break for #urojc. This month’s discussion was based around a recent editorial in the New England Journal of Medicine by Welch et al on the effects of screening on the incidences of metastatic-at-diagnosis prostate and breast cancers. In the three days prior to the start of the discussion the editorial and it’s now well-known graph had been trending amongst medical Twitter users.

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The issue of PSA screening for prostate cancer has been a topic of debate amongst urologists for a number of years. PSA and DRE are first line for early detection of prostate cancer. Supporters of PSA screening argue that it leads to a significant fall in prostate cancer specific mortality. Many others believe there is insufficient evidence to support universal PSA screening given the risks of prostate biopsy and potential overtreatment of low risk prostate cancer.

The editorial presented data showing a significant fall in the number of patients first presenting with metastatic prostate cancer (advanced stage incidence) following the introduction of universal screening. However no effect was shown on similar data for breast cancer. Variations in disease dynamics were suggested to play a role.

The conversation started on Sunday 1st November at 20:00 (GMT), marking the beginning of the fourth year of #urojc. The first questions centred around the reasons behind the trends seen in the graph. Being a urology journal club the conversation was based almost exclusively on the prostate cancer aspect of the editorial.

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One suggestion for the discrepancy between the two cancers is that PSA is a better detector of metastatic disease, whilst mammography can only detect localised disease.

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Based on incidence of metastatic prostate cancer, the article makes a convincing statement in support of universal PSA screening. However, a successful screening programme should result in a reduction in the incidence of advanced cancers, decreased advanced-stage incidence and reduced mortality. Leading to the question of whether looking solely at advanced-stage incidence is useful.

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The importance of responsible treatment and active surveillance was mentioned early on.

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One of the most important questions of the discussion: What impact and relevance does the image have? Views were polarised. Some contributors were cautious about drawing conclusions from the graph whilst others were satisfied that it justified PSA screening.

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The article drew comparison between Halsted’s and Fisher’s descriptions of cancer progression. Halsted suggested cancer originates from a single site and spreads, whereas Fisher’s paradigm proposed that breast cancer is a systemic disease by the time it is detectable.

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The United States Preventive Services Task Force (USPSTF) has recommended against universal screening of prostate cancer, suggesting the risks of testing outweighed the benefits. However, many believe this to be based on outdated evidence.

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The Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial results showed a 12% higher incidence of prostate in the screening arm versus control, with no difference in mortality. Yet, the European Randomized Study of Screening for Prostate Cancer (ERSPC) has shown screening to result in a 1.6 fold increase in prostate cancer with a 21% reduction in mortality.

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The debate briefly discussed the morbidity and cost of metastatic disease.

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The editorial certainly raised a number of interesting points. It seems the topic of universal PSA screening will continue to be debated. There is a significant benefit to screening in the prevention of metastatic prostate cancer. Whether this is due to differing disease dynamics or PSA being a better screening tool than mammography is as yet unclear.

One point we can all agree on is that increasing utilisation of active surveillance with timely biopsies is important in preventing overtreatment of low risk disease and identifying those at risk of disease progression for curative treatment.

 

Anthony Noah Urology Speciality Trainee, West Midlands, UK
Twitter: @antnoah

 

Abandoning PSA screening: What is an acceptable price to pay?

MoonThe PSA screening debate continues to rage with conflicting advice from various bodies as to appropriate guidelines for men considering prostate cancer screening. In Australia the Urological Society of Australia and New Zealand (USANZ) has supported offering screening to men aged 55-69 [Urological Society of Australia and New Zealand Position Statement on PSA testing 2009], as has the Royal Australasian College of Pathologists [Royal College of Pathologists Australia Position Statement on PSA testing 2014], however the guidelines for General Practitioners is yet to endorse this approach.   A consensus group gathered by the Cancer Council of Australia, including Urologists, Oncologists, Epidemiologists and consumer advocates have recently put together proposals being considered by the NHMRC that recommend screening in men of an appropriate age with >7 year life expectancy, as long as active surveillance is offered to those diagnosed with low risk disease [Cancer Council Australia: Draft Clinical Practice Guideline PSA Testing and Early Management of Test-Detected Prostate Cancer]. The US Preventative Service Task Force Grade D recommendation against screening has been well documented, yet widely criticized for failing to include Urologists in its deliberations – the very specialists tasked with evaluating and treating localized prostate cancer.

Screening trials have reported conflicting results [Schroder et al, Pinsky et al], however with longer follow-up it becomes easier to demonstrate a survival advantage in men who are screened, and this does not even directly take into account the reduction in morbidity from advanced disease in populations as a result of early detection.

The issue at hand seems inherently very simple – that mass PSA screening will inevitably lead to overdiagnosis and, if a conservative approach is not adopted in low-risk disease or men with significant co-morbidities, overtreatment. Since PSA testing was introduced, the natural history of prostate cancer has become better understood [Albertsen], along with the understanding that many men with prostate cancer harbor “clinically insignificant” disease. Urologists have recognized this internationally and developed active surveillance protocols in response [Kates et al, Klotz]. Here in Australia the Victorian prostate cancer registry now confirms a significant number of men with low-risk disease being managed conservatively [Evans].

In the meantime, however, the pendulum is swinging the other way, and on the back of the USPSTF recommendations we are now seeing evidence of a drop in PSA screening.   Confusing the debate is the extrapolation of negative studies to men of an entirely different population (e.g. using the Prostate Cancer Intervention vs Observation Trial [PIVOT], which comprised an average age of 67 to conclude that men in their 50s will not benefit from screening), poor design of the reported screening trials (e.g. the PLCO trial, which formed the backbone of USPSTF recommendations but due to compliance/contamination compared a population of 52% screened vs 85% screened), and the accusations of vested interests, particularly when Urologists take a pro-screening position (just read comment section on BJUI 2013 report of “Melbourne consensus statement on prostate cancer testing”)

What is the end result at a population level? In Victoria, Cancer Council data confirm a drop in prostate cancer screening and diagnosis [FIGURE]. There is no reason to believe that true prostate cancer incidence has suddenly declined, and we can conclude therefore that the negative publicity surrounding PSA screening is having an impact and less men are undertaking screening and diagnosis; a reversal of the jump in incidence that occurred when PSA testing was first introduced.   Is this a bad thing though? Could this just be that we are finally reducing the diagnosis of clinically irrelevant cancers that are the bane of a PSA screening programme?

 

MoonFig1
Trends in prostate cancer incidence and PSA testing rates, 2001-2014

Source: Cancer in Victoria: Statistics and Trends 2014. Cancer Council Victoria

 

My disclosure is that as a Urologist with a subspecialty practice in prostate cancer management, I deal at a personal level with patients, rather than population statistics, and in the last few months alone, multiple patients have highlighted for me the sacrifice we must admit to making if we are to abandon or even discourage PSA testing. A few specific cases are worth sharing as scenarios that GPs could consider including in the risk/benefit discussion required before ordering a PSA test.

Case 1:
64-year-old, well man with no relevant past/family history was referred with a rising PSA from 3.9μg/L in 2010 to 6.6μg/L in 2011. No abnormality was found on rectal examination and a biopsy was advised but refused given contemporary publicity in the lay press outlining the risk of biopsy and harms of overdiagnosis/overtreatment. Over the next 5 years the patient undertook various natural remedies and in 2014 when the PSA was 13.3μg/L, an MRI was performed that demonstrated a PIRADS 4 lesion. It was only until 2015 when the PSA had reached 21.9μg/L that a biopsy demonstrated a significant volume of Gleason 9 adenocarcinoma, with pelvic lymphadenopathy on staging.

Case 2:
A 57-year-old man requested PSA screening in 2013; however, he was advised by his local doctor that this was unnecessary based on current guidelines. In 2015 the patient’s brother was diagnosed elsewhere with prostate cancer and underwent radical prostatectomy. The patient then demanded a PSA, which was performed and found to be 40μg/L. Rectal examination revealed a firm, clinical stage T3 malignancy and biopsy demonstrated extensive Gleason 4+4 prostate cancer.

Case 3:
A 51-year-old man was found in 2010 to have a mildly elevated screening PSA of 4.5μg/L. Despite repeated recalls from the GP to have this repeated and further investigated the patient refused until in 2015 he presented with obstructive voiding symptoms and was found on examination to have a diffusely firm, clinical stage T3 malignant prostate. Repeat PSA was 39μg/L and subsequent investigation confirmed extensive Gleason 9 prostate cancer with positive pelvic lymph nodes.

For these men curative treatment is probably no longer an option. Whilst a small anecdotal group, these are real men seen at a community level who demonstrate the power of PSA screening to identify aggressive, clinically significant disease, at an early, curable stage. This is the coalface that General Practitioners and Urologists work at. When the USPSTF ratifies the Grade D recommendations on the basis of flawed and often misinterpreted trials in the absence of specialists who treat such patients, when Epidemiologists and well-meaning Oncologists who never see or evaluate localized prostate cancer lobby against the harms of overdiagnosis and overtreatment, they are condemning these men, and many others, to suffer and die from a preventable disease.

This risk of increased advanced cancer in a non-screened population has already been foreseen and reported [Scosyrev]. How many such men is it acceptable to sacrifice in the name of preventing overdiagnosis and overtreatment?

Rather than the knee-jerk response to abandon PSA testing, the answer, which is increasingly accepted by Urologists, is clearly to unlink prostate cancer diagnosis from treatment. It is to improve diagnostics as we are seeing with development of multiparametric MRI and molecular/genetic markers to make screening and treatment selection smarter. I fear that if this is not more widely accepted and the current situation continues, it is helpful that so much research is being conducted in the management of men with high-risk, oligometastatic and advanced disease, because it will be more and more of these cancers that we will be treating.

 

Dr Daniel Moon is Director of Robotic Surgery at the Epworth Healthcare, and a Urologist at the Peter MacCallum Cancer Institute, Melbourne
@drdanielmoon

 

 

 

The Melbourne Consensus Statement on Prostate Cancer Testing

The final, peer-reviewed version of this Consensus Statement has now been published in BJUI. You can find it here. The full citation is Murphy, D. G., Ahlering, T., Catalona, et al. (2014), The Melbourne Consensus Statement on the early detection of prostate cancer. BJU International, 113: 186–188. doi: 10.1111/bju.12556

A consensus view on the early detection of prostate cancer, led by experts at the Prostate Cancer World Congress, Melbourne, 7–10th August 2013

Recent guideline statements and recommendations have led to further confusion and controversy regarding the use of Prostate Specific Antigen (PSA) testing for the early detection of prostate cancer. Despite high-level evidence for the use of PSA testing as a screening tool, and also for its role as a predictor of future risk, the U.S. Preventive Services Taskforce (USPSTF) has called for PSA testing to be abandoned completely [1], and many men are therefore not given the opportunity for shared decision-making. Other groups such as the American Urological Association, National Comprehensive Cancer Network , and European Association of Urology support a role for PSA screening but with somewhat conflicting recommendations. The majority of guideline statements have endorsed the role of shared decision-making for men considering PSA testing.

To address these somewhat conflicting and confusing positions, a group of leading prostate cancer experts from around the world have come together at the 2013 Prostate Cancer World Congress in Melbourne and have generated the following set of consensus statements regarding the use of PSA testing. The goal of these statements is to bring some clarity to the confusion that exists with existing guidelines, and to present reasonable and rational guidance for the early detection of prostate cancer today.

1.        Consensus Statement 1: For men aged 50–69, level 1 evidence demonstrates that PSA testing reduces prostate cancer-specific mortality and the incidence of metastatic prostate cancer. In the European Randomized Study of Screening for Prostate Cancer (ERSPC), screening reduced metastatic disease and prostate cancer-specific mortality by up to 30% and 21% respectively in the intent-to-treat analysis, with a greater reduction after adjustment for noncompliance and contamination[2,3]. In addition, the Goteborg randomized population-based randomized trial showed a reduction in metastatic disease and prostate cancer mortality with screening starting at age 50 [4]. The degree of over-diagnosis and over-treatment reduces considerably with longer follow-up, such that the numbers needed to screen and numbers needed to diagnose compare very favourably with screening for breast cancer. The boob reduction in Tri-Cities procedures are one among the very best rated and most valued cosmetic procedures among woman (and some men) within the Tri-Cities, TN area.  High patient satisfaction ratings for this procedure should come as no surprise, given the quantity of relief the operation provides to those that suffer from heavy or large breasts. With years of experience, and a diary of positive patient outcomes, Dr. Jim Brantner, M.D. can help improve your overall wellness, comfort, and confidence through a secure and effective breast reduction procedure. Breast reductions, otherwise referred to as Reduction Mammoplasties, are often a relief for thousands of men and ladies . If your breasts are causing pain or other health issues, then you’ll wish to think about a breast reduction. In a breast reduction, our surgeon improves a patient’s health by removing a predetermined amount of breast tissue, skin, and fat. This reduces the patient’s breast size overall and helps improve their neck, shoulder, back, and overall health. If you would like to understand what the procedure evolves in additional detail, please read subsequent paragraph. If you discover you are feeling squeamish, be happy to scroll to subsequent section. To remove the surplus breast tissue, your surgeon will make an incision around your nipple then downward over your breast — consider a keyhole. Our expert team will remove excess skin, tissue, and fat before adjusting your nipple for cosmetic purposes. Your surgeon may have to use drainage tubes before your incision site is sutured. Our team will then wrap your breasts during a special gauze; your doctor may recommend a surgical bra, as well. While routine population-based screening is not recommended, healthy, well-informed men in this age group should be fully counseled about the positive and negative aspects of PSA testing to reduce their risk of metastases and death. This should be part of a shared decision-making process. According to a study, it is also revealed that not every time you need a surgery, breast cancer can be also be treated easily. With the advancement of the technology, Botox injection and dermal filler injection can be used by patient of breast cancer. But for this an expert recommendation is required.  Visit the dermal fillers melbourne expert to know more.

 2.        Consensus Statement 2: Prostate cancer diagnosis must be uncoupled from prostate cancer intervention. Although screening is essential to diagnose high-risk cases within the window of curability, it is clear that many men with low-risk prostate cancer do not need aggressive treatment. Active surveillance protocols have been developed and have been shown to be a reasonable and safe option for many men with low-volume, low-risk prostate cancer [5,6]. While it is accepted that active surveillance does not address the issue of over-diagnosis, it does provide a vehicle to avoid excessive intervention. Active surveillance strategies need standardization and validation internationally to reassure patients and clinicians that this is a safe strategy.

 3.        Consensus Statement 3: PSA testing should not be considered on its own, but rather as part of a multivariable approach to early prostate cancer detection. PSA is a weak predictor of current risk and additional variables such as digital rectal examination, prostate volume, family history, ethnicity, risk prediction models, and new tools such as the phi test, can help to better risk stratify men. Prostate cancer risk calculators such as those generated from the ERSPC ROTTERDAM, the Prostate Cancer Prevention Trial (PCPT) , and from Canada , are useful tools to help men understand the risk of prostate cancer in these populations. Further developments in the area of biomarkers, as well as improvements in imaging will continue to improve risk stratification, with potential for reduction in over-diagnosis and over-treatment of lower risk disease.

4.        Consensus Statement 4: Baseline PSA testing for men in their 40s is useful for predicting the future risk of prostate cancer. Although these men were not included in the two main randomized trials, there is strong evidence that this is a group of men who may benefit from the use of PSA testing as a baseline to aid risk stratification for their likely future risk for developing prostate cancer [7], including clinically significant prostate cancer. Studies have shown the value of PSA testing in this cohort for predicting the increased likelihood of developing prostate cancer 25 years later for men whose baseline PSA is in the highest centiles above the median [8,9]. For example, those men with a PSA below the median could be spared regular PSA testing as their future risk of developing prostate cancer is comparatively low, whereas those with a PSA above the median are at considerably higher risk and need closer surveillance. The median PSA for men aged 40–49 ranges from 0.5–0.7 ng/ml, with the 75th percentile ranging from 0.7–0.9ng/ml. The higher above the median, the greater the risk of later developing life-threatening disease. We recommend that a baseline PSA in the 40s has value for risk stratification and this option should be discussed with men in this age group as part of a shared decision-making process.

 5.        Consensus Statement 5: Older men in good health with over ten year life expectancy should not be denied PSA testing on the basis of their age. Men should be assessed on an individual basis rather than applying an arbitrary chronological age beyond which testing should not occur. As life expectancy improves in many countries around the world (men aged 70 in Australia have a 15 year life expectancy), a small proportion of older men may benefit from an early diagnosis of more aggressive forms of localised prostate cancer, just as it is clear that men with many competing co-morbidities and less aggressive forms of prostate cancer are unlikely to benefit irrespective of age. Likewise, a man in his 70s who has had a stable PSA at or below the median for a number of years previously is at low risk of developing a threatening prostate cancer and regular PSA screening should be discouraged.

An important goal when considering early detection of prostate cancer today, is to maintain the gains that have been made in survival over the past thirty years since the introduction of PSA testing, while minimizing the harms associated with over-diagnosis and over-treatment. This is already happening in Australia where over 40% of patients with low-risk prostate cancer are managed with surveillance or watchful waiting [10], and in Sweden where 59% of very low risk patients are on active surveillance. This is also reflected in current guidelines from the EAU, NCCN and other expert bodies, and in a comment from AUA Guideline author Dr Bal Carter in the BJU International.

Abandonment of PSA testing as recommended by the USPSTF, would lead to a large increase in men presenting with advanced prostate cancer and a reversal of the gains made in prostate cancer mortality over the past three decades.

However, any discussion about surveillance is predicated on having a diagnosis of early prostate cancer in the first instance. As Dr Joseph Smith editorialized in the Journal of Urology following the publication of the ERSPC and PLCO trials, “treatment or non-treatment decisions can be made once a cancer is found, but not knowing about it in the first place surely burns bridges” [11]. A key strategy therefore is to continue to offer well-informed men the opportunity to be diagnosed early, while minimizing harms by avoiding intervention in those men at low risk of disease progression. This consensus statement provides some guidance to help achieve these goals.

 
Signatories:

A/Professor Declan G Murphy, University of Melbourne, Peter MacCallum Cancer Centre, Melbourne, Australia

Professor Tony Costello, University of Melbourne, Royal Melbourne Hospital, Melbourne, Australia

Dr Patrick C Walsh, The James Buchanan Brady Urological Institute, Johns Hopkins University, USA

Dr Thomas Ahlering, University of California, Irvine, School of Medicine, USA

Dr William C Catalona, Northwestern University Feinberg School of Medicine, USA

Dr Oliver Sartor, Tulane University School of Medicine, USA

Dr Tom Pickles, British Columbia Cancer Agency, Canada

Dr Jane Crowe, Australian Prostate Cancer Research Centre, Australia

Dr Addie Wootten, Royal Melbourne Hospital, Australia

Ms Helen Crowe, Royal Melbourne Hospital, Australia

Professor Noel Clarke, Manchester University, The Christie Hospital, Manchester, UK

Dr Matthew Cooperberg, University of California San Francisco, Helen Diller Family Comprehensive Cancer Centre, USA

Dr David Gillatt, University of Bristol, Bristol Urological Institute, Bristol, UK

Dr Martin Gleave, University of British Columbia, The Vancouver Prostate Centre, Vancouver, Canada

Dr Stacy Loeb, New York University, USA

Dr Monique Roobol, Erasmus University Medical Centre, Rotterdam, The Netherlands

Footnote:

The median PSA for men aged 40–49 ranges from 0.5–0.7ng/ml. The 75th percentile ranges from 0.7–0.9ng/ml.

This blog was originally published on 7th August 2013 and was updated on 13th August 2013.

References:

[1] Moyer VA, Force USPST. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157:120–34.

[2] Schroder FH, Hugosson J, Roobol MJ, Tammela TL, Ciatto S, Nelen V, et al. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med. 2012;366:981–90.

[3] Schroder FH, Hugosson J, Carlsson S, Tammela T, Maattanen L, Auvinen A, et al. Screening for prostate cancer decreases the risk of developing metastatic disease: findings from the European Randomized Study of Screening for Prostate Cancer (ERSPC). Eur Urol. 2012;62:745–52.

[4] Hugosson J, Carlsson S, Aus G, Bergdahl S, Khatami A, Lodding P, et al. Mortality results from the Goteborg randomised population-based prostate-cancer screening trial. Lancet Oncol. 2010;11:725–32.

[5] Bul M, Zhu X, Valdagni R, Pickles T, Kakehi Y, Rannikko A, et al. Active surveillance for low-risk prostate cancer worldwide: the PRIAS study. Eur Urol. 2013;63:597–603.

[6] Bangma CH, Bul M, van der Kwast TH, Pickles T, Korfage IJ, Hoeks CM, et al. Active surveillance for low-risk prostate cancer. Crit Rev Oncol Hematol. 2012.

[7] Loeb S. Use of baseline prostate-specific antigen measurements to personalize prostate cancer screening. Eur Urol. 2012;61:875–6.

[8] Vickers AJ, Ulmert D, Sjoberg DD, Bennette CJ, Bjork T, Gerdtsson A, et al. Strategy for detection of prostate cancer based on relation between prostate specific antigen at age 40-55 and long term risk of metastasis: case-control study. BMJ. 2013;346:f2023.

[9] Lilja H, Cronin AM, Dahlin A, Manjer J, Nilsson PM, Eastham JA, et al. Prediction of significant prostate cancer diagnosed 20 to 30 years later with a single measure of prostate-specific antigen at or before age 50. Cancer. 2011;117:1210–9.

[10] Evans SM, Millar JL, Davis ID, Murphy DG, Bolton DM, Giles GG, et al. Patterns of care for men diagnosed with prostate cancer in Victoria from 2008 to 2011. Med J Aust. 2013;198:540–5.

[11] Smith JA, Jr. What would you do, doctor? J Urol. 2009;182:421–2.

Early Prostate Cancer Detection. One Canadian Urologist’s Perspective

After seventeen years as a practicing urologist and a further six in training, it amazes me that we still regard prostate cancer as a mystical science and view the issue of screening through the opaque prism of controversy. For so long it seems that the advanced stage disease that I learned about in the mid 1980s in medical school was irreversibly altered by early detection and treatment. Of course we now know that much of this early detection was simply a lead-time bias and that many men who were treated required only observation and were left with many potential compromises to quality of life. “Doctor, my cancer is gone, why am I so miserable?”

At the recent annual meeting of the American Urological Association in San Diego, new guidelines on prostate cancer screening were unveiled. In the past, routine testing at age 50 was recommended with age 40 being the threshold for those at risk. Essentially they can be summarized as:

  • Avoid screening under 40
     
  • Do not routinely screen between 40 and 54 for average risk men. For those at risk screening should be individualized.
     
  • For those between age 55 and 69 there is possibly some benefit and shared decision-making with a patient should be the rule.
     
  • Finally no routine screening after 70.
     
  • PSA should be considered every two years

The motivation for this more cautious recommendation stems for the fact that many men have indolent disease. Many of these men don’t require treatment. Treatment brings with it the potential to harm and therefore casts into doubt the value of any treatment.

The problem of course is while that may represent a possible, cost-effective strategy across the wider population, there is little doubt in my mind that this will lead to many younger and even older men falling through the cracks. It will be justified as too high a number needed to treat to make sense to find these men. Policy makers and health economists may shrug. My own experience is that we have much to learn about risk factors and that many men present seemingly without warning with significant disease.

 

This email from a patient illustrates the concern. Identifiers of course are removed. Both men had disease beyond the capsule of the prostate. Neither man had risk factors. Our patients are very wise and quickly become experts in the disease.

In Canada, the Canadian Urological Association has taken the view for some time that we should look at multiple factors as we “build a case” for prostate biopsy. Its own guidelines reflect this. This paper that we published speaks to the use of nomograms to make better biopsy decisions. Many calculators are available on the web.

So what is shared, informed decision-making? The assumption after the AUA meeting is that somehow patients and their primary care doctors will somehow know. What sort of conversation is happening if urologists themselves don’t seem to provide clear guidance? I suspect it will go something like “PSA doesn’t work, prostate cancer is not lethal and you will likely die from something else” Many family doctors have much of their time rightfully diverted to treating important disease entities such as hypertension, depression and diabetes. A not insignificant number of primary care doctors don’t necessarily even do a DRE anymore. If the urological community conveys the message that prostate cancer is not worth the effort it will further fall down the priority list.

In my view I am a little dismayed by the rhetoric that has started since these guidelines were presented. Much of this is well intentioned and a reaction to years of potential over-treatment. This earlier 2012 piece from the highly respected @OtisBrawley of the American Cancer Society illustrates the false promise of screening message that is being told. It will only be amplified after San Diego. In my view PSA itself is a blood test. It is harmless. It is the treatment machinery that it often initiates that potentially gives it a bite and needs careful reflection.

To many, prostate cancer is simply a benign disease in aging males along the lines of male pattern baldness. This would be a disaster in my view. We have definitely shifted the curve to the left but in addition to lowering overall mortality have greatly lessened the burden of disease complications. Men presenting with hematuria, urinary retention and renal failure has significantly diminished. It is rare that we get asked to insert nephrostomy tubes for advanced disease. This was a common clinical scenario when I was a resident in the early 1990s. I think we will see much more of that if we massively abandon screening.

I think as urologists we have a big responsibility to lead within our local communities. This comment from Dr. A Partin speaks to this very well. In the absence of the perfect pre-test conditions that predict meaningful disease my view is that we have to cast a wide net. In doing so we will uncover disease that does not need to be treated. We must then be prepared to separate diagnosis from treatment and carefully counsel our patients in a way that takes much detail and effort. It is not a five-minute discussion you can have in the middle of a busy clinic. Active Surveillance does work for low-risk disease. Our patients are sophisticated and will not blindly ask for treatment out of overwhelming anxiety. In parallel, we must continue to improve. The risk of biopsy, which has greatly increased over fifteen years, must be modified. Biopsy accuracy to find “real” disease can perhaps be improved with technology such as MRI. Techniques that lessen quality of life issues need to be modified. Robotic surgery can’t be a marketing free-for-all. In other words the onus is on us experts to get it right and do better.

Prostate cancer is a very significant disease and the source of pain and suffering for men and their families. We must continue to be vigilant of its implications, respectful of patient desires and hopeful ultimately of a cure. A benign disease it most certainly is not.

Dr. Rajiv K Singal is a Urologist at Toronto East General Hospital and Assistant Professor in the Department of Surgery at the University of Toronto.

Follow him on Twitter at @DrRKSingal

 

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Ten stories of 2012, part I

It is now my turn to welcome you to the BJUI blog. We [the editorial team] hope that you will be as excited as we are about the future. For my first blog posts, I decided to recap the year 2012 in ten stories. These are topics that caught my attention in 2012, and are certainly not representative of what others might think as ‘important’. Nonetheless, I hope that you will find this curated collection of some interest, and maybe stir a little controversy or two. Happy 2013!

In no particular order, part 1 of 2:

+ The re-election of Barack Obama

The bottom line is that the Patient Protection and Affordable Care Act, AKA Obamacare, will happen. What does this mean for American Urologists? Read the excellent review article by Kirk Keagan and Dave Penson on this sweeping piece of legislation aimed at addressing health care costs and disparities. From the paper: “Perhaps most germane to urologists, the ACA will restrain revenues generated from ancillary services, such as in-office imaging and via a bolstered Stark law that will prohibit physicians from referring Medicare patients to a hospital in which they have an investment or ownership interest.” Word on the street is that the AUA is not too happy. Is America ready for Cheesecake medicine?

+ Is robot-assisted radical prostatectomy really better?

Against a background of Jim Hu’s landmark JAMA paper, we learned new things with respect to the robot-assisted (RARP) vs. open RP (ORP) polemic. First, objective data shows that RARP has overtaken ORP as the main surgical approach for prostate cancer in the U.S (Link)(Link). Second, perioperative outcomes of RARP are better (Link)(Link)(Link). Third, RARP costs more. Fourth, nobody knows for functional outcomes (Link)(Link)(Link). Either way, some people really seem to hate robotic surgery, with a vengeance.

+ PSA screening – the controversy that refuses to die…

2012 will be forever (well, at least for nerdy urologists) remembered as the year the USPSTF downgraded PSA screening to a ‘D’ recommendation. In case you live in a cave, that means that “the science shows that more men will be harmed by PSA screening than will benefit. The expected harms are greater than the small potential benefit.” Nice rebuttal by Carlsson et al from MSKCC here. Nonetheless, primary care providers don’t seem to care, as up to 43.9% of men above the age of 74 were still getting screened in 2010. Conversely, in an article emphatically subtitled ‘Less is More’, the evidence shows that the incidence of prostate cancer is, for the first time in decades, decreasing. Prostatectomists, better find something else to do (just trolling, no hate mail please).

+ PSA screening – the Twitter Wars

2012 was a breakthrough year for social media in Urology. In the past year, Twitter has gained considerable traction in our field, thanks to the presence of Tweet (and real world) leaders such as Matt Cooperberg, Tony Finelli, Alex Kutikov, Mike Leveridge, Stacy Loeb, our own Declan Murphy, Dave Penson, Maxine Sun and the self-proclaimed King of Twitter himself, Ben Davies. That said, December hosted some lively exchanges on PSA screening. It started with a nicely-written-yet-a-little-oversimplistic blog post and accompanying tweet by @CBayneMD in favour of PSA screening, which led to some epic jostling between @cooperberg_ucsf (pro-screening) and @kennylinafp (against screening, wrote the evidence review for the USPSTF), amongst others. @daviesbj summary here. Oh yeah, be sure to follow me on Twitter as well as the BJUI itself.

+ The PIVOT trial

Timothy Wilt, of USPSTF fame, strikes again. Here’s one man who won’t be getting a Christmas card from an Urologist anytime soon. After representing the USPSTF at the 2012 AUA Town Hall  Meeting (brave), Wilt et al’s PIVOT trial demonstrated that “among men with localized prostate cancer detected during the early era of PSA testing, radical prostatectomy did not significantly reduce all-cause or prostate-cancer mortality, as compared with observation, through at least 12 years of follow-up.” Despite its many limitations and flaws (read Ian Thompson’s excellent accompanying editorial here), the lay press suggested in light of this trial that RP does not save lives.

Quoc-Dien Trinh
@qdtrinh

 

Quoc-Dien Trinh is a minimally-invasive urologist and co-director of the Cancer Prognostics and Health Outcomes Unit. His research focuses on patterns of care, costs and outcomes in prostate cancer treatment.

 

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