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【资讯翻译】PSA Screening Should Be an Opt-In Test, Not Opt-Out

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发表于 2015-10-20 10:28:55 | 显示全部楼层 |阅读模式
PSA Screening Should Be an Opt-In Test, Not Opt-Out

In 1991, Dr William Catalona and colleagues[1] published a report in the New England Journal of Medicine describing the use of prostate-specific antigen (PSA) as a screening test for prostate cancer. I think it's easy to say that healthcare in men has not been the same since.

To step back and define things a little better, I think it's important to understand the requirements of a good screening test. It should be easy to perform, be relatively inexpensive, and affect mortality specifically due to the disease being screened for. That the PSA blood test meets the first two criteria is fairly clear. It's the last criterion that has been debated for years.

Two trials were published in the same issue of the New England Journal of Medicine in 2009 and gave conflicting results for screening.[2,3] The trial that did report a benefit of screening also gave the caveat that a number of men were overtreated on the basis of screening.

Even as far back as 1954, Dr L.M. Franks[4] reported that 31% of men older than 50 years were found to have prostate cancer on autopsy. With the advent of PSA, we have become much more likely to find these cancers—which would never have any clinical impact on these men—and then subject patients to treatment that they may never have required. As a result, many men have experienced both short- and long-term toxicities that are often very problematic. In addition, men with a shortened life expectancy owing to other medical issues have continued to be screened. One report has even estimated that the number of these men could be nearly 800,000.[5]

Because of incomplete data, the US Preventive Services Task Force (USPSTF) first put out a recommendation in 2008 stating that PSA screening should be limited to men with at least a 10-year life expectancy. In 2012, the USPSTF expanded their recommendation to state that PSA screening should not be performed, regardless of age.[6] The expansion was based on recognition that the harms of overdetection and treatment outweighed the benefit gained.

There has been significant and often vehement debate regarding these recommendations. The American Urological Association initially argued strongly against the USPSTF recommendations but has since evolved its guidelines to state that PSA screening could be considered in men aged 55-69 years only after significant discussion and "shared decision-making."[7]

Given that most screening is performed by primary care physicians and they most commonly pay attention to the USPSTF, it should be expected that screening rates have fallen. Interestingly enough, a review of PSA screening after the 2008 USPSTF statement did not show an impact on screening of men older than 75 years.[8]

More recently, a review of screening practices since the 2012 USPSTF recommendations was published in the Journal of Clinical Oncology.[9] They reported that screening in men aged 60-74 years declined from 51.2% to 43.6%. The screening rate decreased from 33.2% to 24.8% in men aged 50-59 years, whereas men older than 75 years had screening rates drop from 43.9% to 37.1%.

The concerning data showed that men with an expected survival of 9 years or less were still being screened at a rate of up to 32%. In other words, about 1.4 million men who are older than 65 years, but are expected to live less than 9 years, are being screened with PSA testing.

So the next question has to be, "What do we do with those men who are screened, arguably inappropriately, and found to have prostate cancer?" The notion of active surveillance has been recognized for more than 20 years and certainly has a role in specific men.

Investigators at Johns Hopkins recently reported their experience with active surveillance since 1995 in the Journal of Clinical Oncology.[10] They report on 1298 men with either "very low-risk" (stage T1c, Gleason score ≤ 6, two or fewer positive cores, and a maximum of 50% involvement in any one core) or "low-risk" (stage T2a or less, PSA level less than 10 ng/nL, and Gleason score ≤ 6) disease. They were followed with semiannual PSA testing and rectal exams, and annual biopsies.

They found some very interesting things. Only 49 of the 1289 men died during the follow-up period, and only two of those deaths were from prostate cancer. Men were 19 times more likely to die of cardiovascular disease than prostate cancer. An advancement of grade on the annual biopsies led to a recommendation for intervention. This only occurred in 22% of men in the very low-risk group and 31% of men in the low-risk group at 15 years. Outcomes of those interventions were generally excellent, with only 8% showing biochemical failure.
If you are a primary care physician, PSA screening for prostate cancer should be thought of as an "opt-in" as opposed to an "opt-out" test. In other words, you need to establish a significant reason to screen and discuss with the patient what adverse outcomes the screening may lead to. If the patient has an estimated 9 years or less to live, screening should not be an option at all.

If you are faced with a man diagnosed with prostate cancer and he falls into the very low-risk or low-risk group, you should strongly consider active surveillance. You certainly would not be putting him at significant risk, and you would be probably saving him from very real toxicities.

信源地址:http://www.medscape.com/viewarticle/852539

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发表于 2015-10-20 10:44:54 | 显示全部楼层
这篇我要了。。。

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发表于 2015-10-22 18:47:33 | 显示全部楼层
前列腺特异性抗原(PSA)筛查应该是选择性加入测试而非选择性退出测试

1991年, William Catalona医生和他的同事在新英格兰杂志上发表了一篇使用前列腺特异性抗原(PSA)作为前列腺癌的筛选检测的报告。我认为可以说至此人类医疗健康变得不同。

重新审视并且更好的定义PSA事物,我认为理解一种筛选检测的需求是非常重要的。进行这种检测应该比较容易,相对便宜并且能够影响所筛选疾病的致死率。前列腺特异性抗原的检测满足前两种要求是比较明确的。但是大家一直争论PSA检测是否满足第三种要求。

在2009年的新英格兰杂志的同一期上发表了两篇结果相互冲突的筛选临床实验。这项临床实验报告了筛选的有利作用以及给出了基于筛查对一部分病人治疗过度的警告。

甚至早在1954年,L.M.Franks博士报道了31%的年龄大于50岁的男子通过尸检被发现有前列腺癌。随着PSA的到来,使得诊断这些癌症患者变得似乎更加容易,这些癌症患者可能没有任何临床症状,并且这些癌症患者随后接受了可能不需要的治疗。结果很多人经历了或长或短的毒性治疗的问题。另外,有较短生命预期的人由于其他医疗问题继续筛查。有一项报告称这类人接近800000人。

由于不充分的数据,美国预防服务工作队(USPSTF)首先在2008年提出一项建议表述PSA筛选应该限制在至少有十年生存期的人群中。在2012年,USPSTF详述了他们的建议表明不论年龄PSA筛选不应该被进行。这项建议是基于过度的诊断和治疗超过了所获得的利益的认识。

关于这些建议已经有很重要和激烈的争议。美国泌尿协会起初反对USPSTF建议但是在激烈的争论以及共同决定后,其章程表明PSA筛选可以考虑在55~69岁的人群中进行。

考虑到大多数的筛选是由初级护理医生进行的且他们大多数习惯关注于USPSTF,期待筛选率已经下降了。足够有趣的是,在2008年USPSTP陈述后关于PSA筛选的一篇综述表明在大于75岁的人群中PSA筛选是没有效果的。

最近以来,一篇关于自从2012USPSTF建议以来PSA筛查实践的综述以来在临床肿瘤学杂志发表。他们报道称在60到74岁年龄的人筛查由51.2%下降到43.6%。这种筛查率由在50到59岁年龄的人群中的33.2%下降到24.8%,然而年龄在75周岁的筛查率由43.9%下降到37.1%。

令人担忧的数据表明期待存活率大于9年或者更少的筛查率达到了32%。 换句话说,大约140万的大于65岁的人群的通过PSA筛查的期待存活率是少于9年的。

所以下一个问题是:“我们怎样处理那些经过筛查被证实患有前列腺癌?”积极检测的原则已被接受了超过20年并且毫无疑问的在特殊的人群。

约翰霍普金斯的研究者最近在临床肿瘤学杂志报道了他们的自1995年积极监测的经验。他们报道了1298的人群,这部分人包括极低风险(T1阶段,格里森系数≤ 6,2个或者更少的阳性核心,以及最大的50%包含在任何的一个核心)或者低风险(T2a阶段或者更低,PSA的水平低于10ng/nl以及格里森系数≤ 6)。他们随访每半年的PSA检测以及直肠检测以及年度活体检查。



他们发现一些有趣的结果。在1289人中仅有49人在随访的过程中死亡,但是仅有2人是死于前列腺癌症的。死于心脏疾病的人是死于前列腺癌的人数的19倍。一项年度组织检测的等级提升引起干预建议。在极低风险的群体中有22%的发生,在15年的低风险人群的这一比例有31%。这些干预的建议中体来说是不错的仅有8%的人群生化检测失败。

如果你是一名初级护理医生,前列腺癌证的PSA筛查应该是选择性加入而非选择性退出的检测项目。换句话说,你需要有充分的理由去进行筛查并且需要同病人商讨筛查可能引发的反面作用。如果这个病人的生存预期为9年或者更少,PSA筛查根本就没有必要。

如果你面对一个诊断为前列腺癌症的病人,并且他被分类为极低风险或者低风险的群体中,你应该考虑积极的监测。你肯定不会将他置于显著的风险中,并且你应该会从实际的毒力效应中去挽救他。

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 楼主| 发表于 2015-10-23 17:08:25 | 显示全部楼层
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