Letters
randomised cross-over study of the effects on health-related quality of life, physical capacity, thirst and morbidity. Scand Cardiovasc J. 2008;42(5):316-322. 3. Travers B, O’Loughlin C, Murphy NF, et al. Fluid restriction in the management of decompensated heart failure: no impact on time to clinical stability. J Card Fail. 2007;13(2):128-132. 4. Aliti GB, Rabelo ER, Clausell N, Rohde LE, Biolo A, Beck-da-Silva L. Aggressive fluid and sodium restriction in acute decompensated heart failure: a randomized clinical trial. JAMA Intern Med. 2013;173(12):1058-1064.
Why I Will Continue to Screen Prostate-Specific Antigen for Myself and Other Appropriate Men To the Editor The slogan “Less Is More” has an Orwellian ring to it, especially as government committees usurp the individualized decision making of clinicians. The recent editorial by Katz1 seems to imply that when a healthy 68-year-old man asks me to order a screening prostate-specific antigen (PSA) test for him, I should instead offer him an end-of-life discussion. I cannot apply results from a PSA study done on a Department of Veterans Affairs population, notorious for high rates of smoking and other bad habits, to my well-educated and health-conscious seniors who eat right, exercise, and stopped smoking in 1963. Because of their adherence to a hearthealthy lifestyle, my seniors have a longer life expectancy to protect, altering the balance of benefits and risks compared with other populations. The large trials may have failed to demonstrate the full value of PSA screening because they were not performed correctly. We know that PSA is a noisy measurement; many benign causes can make it rise sharply, such as infection, trauma, too much sex, or not enough sex. To require a biopsy for an isolated PSA test result over any fixed threshold does not make biological sense. Some men have large benign prostates or prostates with only low-grade cancers that can be observed. Prostate-specific antigen velocity is a more plausible correlate to the growth of a dangerous malignancy. Low-grade prostatitis or urinary tract infections must be ruled out prior to biopsy. The large PSA trials suffered from undersampling. The noise corrupting the PSA signal has the property of always increasing the PSA level; therefore it can be filtered by measuring the PSA several times over a period of time before biopsy and discarding all but the lowest value, which will be the closest to the underlying PSA signal. Measuring PSA once per year is gross undersampling of this noisy signal. More information is almost always beneficial. Harms can be minimized by watchful waiting. We need a large trial of PSA measured every 3 months, a biopsy criterion incorporating PSA velocity, and an adaptive increase in PSA sampling before biopsy. If no benefit is seen, then I will stop screening PSA. David L. Keller, MSEE, MD Author Affiliation: Providence Medical Group, Torrance, California. Corresponding Author: David L. Keller, MSEE, MD, Providence Medical Group, PO Box 14295, Torrance, CA 90503 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Katz MH. Can we stop ordering prostate-specific antigen screening tests? JAMA Intern Med. 2013;173(10):847-848. 164
In Reply I do not see my recommendation for abandoning screening with the prostate-specific antigen (PSA) as Orwellian. I think of it as in the spirit of Hippocrates: First, do no harm. When I think of a healthy 69-year-old man, as described by Dr Keller, I do not want to have an end-of-life discussion with him; I want to keep him healthy, continent, and (ideally) enjoying a great sex life. I do not want to subject him to tests that may cause a cascade of events that diminish the quality of his life, without data indicating that I am substantially increasing his survival. At the present time, the data do not show a survival advantage with PSA screening, which has led the US Preventive Services Task Force to conclude that “there is moderate certainty that the benefits of PSA-based screening for prostate cancer do not outweigh the harms.”1(p122) I do not agree that “more information is almost always beneficial.” When a man is told that his PSA level is elevated, he worries. A trial measuring PSA level every 3 months, as recommended by Dr Keller, might result in more biopsies, depending on what criterion is used for deciding to do a biopsy and how PSA velocity is incorporated into the criterion. Certainly, measuring the PSA every 3 months will increase patient worry and costs. Watchful waiting can minimize the complications of treatment of prostate cancer but places the patient under a cloud where they are told they have cancer and that their physicians are watching to see if it spreads. This likely explains why only 7% of men with localized prostate cancer in a recent registry study chose watchful waiting, while 50% chose prostatectomy, 12%, external-beam radiation, 13%, brachytherapy, 4%, cryoablation, and 14%, androgen deprivation monotherapy,2 even though there is no convincing data to support the superiority of these more invasive options. Screening is for persons who are asymptomatic. We should leave that happy state alone unless we are sure we are doing more good than harm. Prostate-specific antigen testing does not meet that criteria. Mitchell H. Katz, MD Author Affiliation: Los Angeles County Department of Health Services, Los Angeles, California. Corresponding Author: Mitchell H. Katz, MD, Los Angeles County Department of Health Services, 313 N Figueroa St, Room 912, Los Angeles, CA 90012 ([email protected]). Conflict of Interest Disclosures: None reported. Disclaimer: The views presented are those of Dr Katz and do not necessarily reflect the views of the County of Los Angeles. 1. Moyer VA. US Preventive Services Task Force. Screening for prostate cancer: US Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2012;157(2):120-134. 2. Cooperberg MR, Broering JM, Carroll PR. Time trends and local variation in primary treatment of localized prostate cancer. J Clin Oncol. 2010;28(7):1117-1123.
Further Thoughts on Why There Are Good Data Supporting the Inferior Vena Cava Filter To the Editor Previously, we were not responding to the intended comments by Dr Hoffer.1 Herein, we address his points. First, Dr Hoffer1 claims that inferior vena cava (IVC) filters decrease pulmonary embolism (PE), while increasing deep vein thrombosis (DVT), and that this trade-off is “arithmetic”
JAMA Internal Medicine January 2014 Volume 174, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Georgia User on 06/04/2015
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randomised cross-over study of the effects on health-related quality of life, physical capacity, thirst and morbidity. Scand Cardiovasc J. 2008;42(5):316-322. 3. Travers B, O’Loughlin C, Murphy NF, et al. Fluid restriction in the management of decompensated heart failure: no impact on time to clinical stability. J Card Fail. 2007;13(2):128-132. 4. Aliti GB, Rabelo ER, Clausell N, Rohde LE, Biolo A, Beck-da-Silva L. Aggressive fluid and sodium restriction in acute decompensated heart failure: a randomized clinical trial. JAMA Intern Med. 2013;173(12):1058-1064.
Why I Will Continue to Screen Prostate-Specific Antigen for Myself and Other Appropriate Men To the Editor The slogan “Less Is More” has an Orwellian ring to it, especially as government committees usurp the individualized decision making of clinicians. The recent editorial by Katz1 seems to imply that when a healthy 68-year-old man asks me to order a screening prostate-specific antigen (PSA) test for him, I should instead offer him an end-of-life discussion. I cannot apply results from a PSA study done on a Department of Veterans Affairs population, notorious for high rates of smoking and other bad habits, to my well-educated and health-conscious seniors who eat right, exercise, and stopped smoking in 1963. Because of their adherence to a hearthealthy lifestyle, my seniors have a longer life expectancy to protect, altering the balance of benefits and risks compared with other populations. The large trials may have failed to demonstrate the full value of PSA screening because they were not performed correctly. We know that PSA is a noisy measurement; many benign causes can make it rise sharply, such as infection, trauma, too much sex, or not enough sex. To require a biopsy for an isolated PSA test result over any fixed threshold does not make biological sense. Some men have large benign prostates or prostates with only low-grade cancers that can be observed. Prostate-specific antigen velocity is a more plausible correlate to the growth of a dangerous malignancy. Low-grade prostatitis or urinary tract infections must be ruled out prior to biopsy. The large PSA trials suffered from undersampling. The noise corrupting the PSA signal has the property of always increasing the PSA level; therefore it can be filtered by measuring the PSA several times over a period of time before biopsy and discarding all but the lowest value, which will be the closest to the underlying PSA signal. Measuring PSA once per year is gross undersampling of this noisy signal. More information is almost always beneficial. Harms can be minimized by watchful waiting. We need a large trial of PSA measured every 3 months, a biopsy criterion incorporating PSA velocity, and an adaptive increase in PSA sampling before biopsy. If no benefit is seen, then I will stop screening PSA. David L. Keller, MSEE, MD Author Affiliation: Providence Medical Group, Torrance, California. Corresponding Author: David L. Keller, MSEE, MD, Providence Medical Group, PO Box 14295, Torrance, CA 90503 ([email protected]). Conflict of Interest Disclosures: None reported. 1. Katz MH. Can we stop ordering prostate-specific antigen screening tests? JAMA Intern Med. 2013;173(10):847-848. 164
In Reply I do not see my recommendation for abandoning screening with the prostate-specific antigen (PSA) as Orwellian. I think of it as in the spirit of Hippocrates: First, do no harm. When I think of a healthy 69-year-old man, as described by Dr Keller, I do not want to have an end-of-life discussion with him; I want to keep him healthy, continent, and (ideally) enjoying a great sex life. I do not want to subject him to tests that may cause a cascade of events that diminish the quality of his life, without data indicating that I am substantially increasing his survival. At the present time, the data do not show a survival advantage with PSA screening, which has led the US Preventive Services Task Force to conclude that “there is moderate certainty that the benefits of PSA-based screening for prostate cancer do not outweigh the harms.”1(p122) I do not agree that “more information is almost always beneficial.” When a man is told that his PSA level is elevated, he worries. A trial measuring PSA level every 3 months, as recommended by Dr Keller, might result in more biopsies, depending on what criterion is used for deciding to do a biopsy and how PSA velocity is incorporated into the criterion. Certainly, measuring the PSA every 3 months will increase patient worry and costs. Watchful waiting can minimize the complications of treatment of prostate cancer but places the patient under a cloud where they are told they have cancer and that their physicians are watching to see if it spreads. This likely explains why only 7% of men with localized prostate cancer in a recent registry study chose watchful waiting, while 50% chose prostatectomy, 12%, external-beam radiation, 13%, brachytherapy, 4%, cryoablation, and 14%, androgen deprivation monotherapy,2 even though there is no convincing data to support the superiority of these more invasive options. Screening is for persons who are asymptomatic. We should leave that happy state alone unless we are sure we are doing more good than harm. Prostate-specific antigen testing does not meet that criteria. Mitchell H. Katz, MD Author Affiliation: Los Angeles County Department of Health Services, Los Angeles, California. Corresponding Author: Mitchell H. Katz, MD, Los Angeles County Department of Health Services, 313 N Figueroa St, Room 912, Los Angeles, CA 90012 ([email protected]). Conflict of Interest Disclosures: None reported. Disclaimer: The views presented are those of Dr Katz and do not necessarily reflect the views of the County of Los Angeles. 1. Moyer VA. US Preventive Services Task Force. Screening for prostate cancer: US Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2012;157(2):120-134. 2. Cooperberg MR, Broering JM, Carroll PR. Time trends and local variation in primary treatment of localized prostate cancer. J Clin Oncol. 2010;28(7):1117-1123.
Further Thoughts on Why There Are Good Data Supporting the Inferior Vena Cava Filter To the Editor Previously, we were not responding to the intended comments by Dr Hoffer.1 Herein, we address his points. First, Dr Hoffer1 claims that inferior vena cava (IVC) filters decrease pulmonary embolism (PE), while increasing deep vein thrombosis (DVT), and that this trade-off is “arithmetic”
JAMA Internal Medicine January 2014 Volume 174, Number 1
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of Georgia User on 06/04/2015
jamainternalmedicine.com
