Is there another nail in the coffin of routine PSA screening? That's one interpretation of a study in this issue of the New England Journal of Medicine, juxtaposing quality of life (QOL) against consequences of routine PSA screening and basically concluding that these factors are just about equal. As Rick and I conclude in PodMed, to us that means the majority of men can just say no, although some high risk groups may consider continuing routine screening.
Now this study is admittedly heavy wading, utilizing data from the European Randomized Study of Screening for Prostate Cancer (ERSPC) to calculate a relative reduction in prostate cancer mortality among a group of men who were screened using PSA of 29%, after adjustment for selection bias. This data is robust; over 160,000 men were randomized to PSA screening or not, with a screening interval of 2 or 4 years. The object of course, of screening is to reduce deaths due to prostate cancer, increase the number of years of life, and reduce the incidence of advanced disease. Yet as so many studies have demonstrated, these objectives are achieved at substantial cost, as considered in this study, of the impact of outcomes such as urinary incontinence and sexual dysfunction (impotence) on an individual man's quality of life.
So how was QOL assessed? Various statistical models were utilized, giving rise to 'utility estimates' for different health states ranging from full health to death or worst imaginable health. Data from the ERSPC on bowel incontinence, urinary incontinence and erectile dysfunction was included as were various time intervals.
The paper reveals some important data:
Two specific studies on quality of life after prostate-cancer treatment have been performed for men participating in Rotterdam and Sweden.9,39 Preoperatively, 1 to 2% of the men were incontinent and 31 to 40% were impotent. At 18 to 52 months after treatment, incontinence was reported in 6 to 16% of the men undergoing radical prostatectomy and in 3% of those undergoing radiation therapy (Table 2Table 2Rates of Incontinence and Erectile Dysfunction Associated with Prostate-Cancer Treatments at Two ERSPC Centers.). At 6 to 52 months after treatment, impotence among men who were potent preoperatively was reported in 83 to 88% of those undergoing radical prostatectomy and in 42 to 66% of those undergoing radiation therapy."
Wow! That's a lot of erectile dysfunction! And the urinary incontinence can't be dismissed either. As Rick so aptly puts it in the podcast, if you told a man that he might live an additional 8 years or so post-treatment but that he'd be either impotent or have to wear a diaper, or both, how might that change his decision to undergo screening at all? Our conclusion it that this is something that must be put to men individually, allowing them to participate fully in the decision making process after being educated about the issue. Clearly, what is really needed is a way to distinguish prostate cancers that are likely to be aggressive from their more indolent cousins, so that overtreatment can be avoided. For higher risk men, such as those with a family history of early prostate cancer death, screening is still likely be of benefit with regard to life expectancy.
Other studies this week include another look at routine aspirin use and cancer mortality in the Journal of the National Cancer Institute, a very short paper in Archives of Internal Medicine on tests ordered on day of discharge, and the association between stroke, bleeding, atrial fibrillation and chronic kidney disease in NEJM. Until next week, y'all live well.