515 - Cancer Survivorship, Screening for Prostate CA, I Mean No One …

From the Literature

1)  Cancer Survivorship Guidelines Used in Primary Care?

Cancer survivorship care encompasses much of the usual work of primary care: assessment of risk, delivery of preventive services, treatment of mood disorders and altered family dynamics. However, survivorship care is not a frequently discussed aspect of primary care. It represents an increasingly large facet of primary care where specialists return our patients to us after a long, complex treatment course. We often feel uncertain – concerned about relapse and a complicated monitoring course. And yet, the argument for return to primary care after the management of the complex medical issue is hardly controversial.

To assist with this care, there exist several comprehensive cancer survivorship guidelines – the most primary care-oriented are put out by the American Cancer Society. But are they well-used by primary care clinicians? A survey study attempts to answer this question. Using a curated physician survey service, the researchers asked primary care clinicians (family medicine, internal medicine, OB-GYN) about the use of specific survivorship guidelines, whether they were trained on survivorship, and whether those clinicians performed specific survivorship care tasks: “…surveillance for cancer recurrence, screening for a new cancer, evaluating late and long-term adverse treatment effects, counseling on smoking cessation, counseling on diet and physical activity, treating anxiety and depression, assessing genetic cancer risk or managing patients with genetic syndromes, treating pain from cancer treatment, treating fatigue, treating sexual dysfunction genetic risk, screening for recurrence…”

Most clinicians used surveillance guidelines (78%) and comprehensive survivorship guidelines (62%). Eighteen percent used no guidelines and only 17% say they received training in survivorship care. Clinicians most commonly provided smoking cessation services, treatment for mood disorders, and diet/exercise advice. Least often, they provided genetic screening and treatment for sexual dysfunction. Clinicians who reported using guidelines and/or receiving training in survivorship care reported more provision of the needed services.

John’s Comments:

This is a survey study of clinicians’ self-reported behavior from a panel who chose to answer surveys for some compensation, so caveat lector. However, it is a useful reminder of our very broad but powerful role in our patients’ lives, as well as of the power of guidelines and other supports to allow us to provide the care needed for the complex spectra of their lives. One of these supports are specific cancer surveillance EHR reminders, which our EHR at Carilion will be soon implementing. Such reminders can help us feel more confident delivering this needed care.

Reference:

·         Townsend JS, Rohan EA, Sabatino SA, Puckett M. Use of Cancer Survivorship Care Guidelines by Primary Care Providers in the United States. J Am Board Fam Med. Published online September 29, 2023. Link

From the Guidelines and the American Urological Association (AUA)

2)  Screening for the Early Detection of Prostate Cancer (PCa)

Prostate cancer is the most commonly diagnosed non-cutaneous malignancy in American men. There will be an estimated 288,300 prostate cancer diagnoses and 34,700 deaths from prostate cancer in the United States in 2023.  Significant advances have been made in early detection, especially with the increasing availability and use of biomarkers as well as multi-parametric magnetic resonance imaging (mpMRI).

In July of 2023, the American Urological Association (AUA) in collaboration with the Society of Urologic Oncology published an updated guideline on the screening and early detection of prostate cancer.  The guideline addresses PSA-based screening, considerations for initial and repeat biopsy, and biopsy technique based on a systematic review of recently published literature, with the goal of identifying clinically significant prostate cancer while minimizing potential harms (eg, anxiety, false positives, overdiagnosis of low-risk cancer, and side-effects from prostate biopsy).

Selected Recommendations with strength of recommendation and evidence grade include (Note:  “Clinical Principle” in this context means a statement about a component of clinical care that is widely agreed upon by urologists or other clinicians for which there may or may not be evidence in the medical literature):

For PSA Screening

·         Engage in shared decision-making (SDM) with men for whom screening would be appropriate and proceed based on their values and preferences. (Clinical Principle)

·         When screening, use PSA as the first screening test. (Strong Recommendation; Evidence Level: Grade A)

·         For men with a newly elevated PSA, repeat the PSA prior to a secondary biomarker, imaging, or biopsy. (Expert Opinion)

·         Begin screening and offer a baseline PSA test to men between ages 45-50. (Conditional/Grade B)

·         Offer screening beginning at age 40-45 for men at increased risk of developing prostate cancer based on the following factors: Black ancestry, germline mutations, strong family history of prostate cancer. (Strong/Grade B)

·         Offer regular prostate cancer screening every 2 to 4 years to men aged 50-69. (Strong/Grade A)

·         May personalize the re-screening interval, or decide to discontinue screening, based on patient preference, age, PSA, prostate cancer risk, life expectancy, and general health following SDM. (Conditional/Grade B)

·         May use digital rectal exam (DRE) alongside PSA to establish risk of clinically significant PCa. (Conditional/Grade C)

·         For men undergoing screening, should not use PSA velocity as the sole indication for a secondary biomarker, imaging, or biopsy. (Strong/Grade B)

·         Clinicians and patients may use validated risk calculators to inform the SDM process regarding prostate biopsy. (Conditional/Grade B)

Prior to Undergoing Biopsy: 

·         Should inform patients undergoing a prostate biopsy that there is a risk of identifying a cancer with a sufficiently low risk of mortality that could safely be monitored with active surveillance (AS) rather than treated. (Clinical Principle)

·         May use adjunctive urine or serum markers when further risk stratification would influence decisions regarding whether to proceed with biopsy. (Conditional/Grade C)

·         May use either a transrectal or transperineal biopsy route when performing a biopsy. (Conditional/Grade C)

Mark’s Comments:

To provide contrast, in 2018 the USPSTF gave a “C” recommendation for PCa screening in men between ages 55-69 using a SDM process to provide a balance of potential benefits and harms of screening as well as patient context for an individual patient’s risks.  The Task Force gave a “D” recommendation for screening in men > 70. 

As technology and a better understanding of nuances in the screening and detection process have advanced (use of additional biomarkers, PSA density/velocity, MRI, improved biopsy techniques, genetic testing), the importance of continuing to revisit this area is essential for we who provide primary health care for men.  It appears we’ve advanced beyond the “do it/don’t do it” debate toward a more nuanced approach (at least in theory).  The AUA provides an "Early Detection Algorithm" which can be helpful to guide clinical decision-making.  I personally have begun gravitating toward earlier conversations with the men I care for (ages 40-45) with consideration of a baseline PSA to help guide future risk at age 45 for average risk men.  That approach is more in line with this guideline and other literature I have been reading.  At the least, we owe it to our patients to educate them about their prostate and what is presently available to provide screening for them. 

References:

·         Wei JT, Barocas D, Carlsson S, et al. Early detection of prostate cancer: AUA/SUO guideline part I: prostate cancer screening. J Urol. 2023;210(1):45-53. Link

·         Wei JT, Barocas D, et al. Early detection of prostate cancer: AUA/SUO guideline part II: considerations for a prostate biopsy. J Urol. 2023;210(1):54-63.  Link

·         USPSTF:  Prostate Cancer Screening  - Final Recommendation May 2018.  Site

·         USPSTF Infographic – Is Prostate Cancer Screening Right for You?  Infographic

From PeerARTx  and the PRX90 Process ( www.PeerRxMed.org )

3)  No One Should Care Alone

“Sometimes life is too hard to be alone, and sometimes life is too good to be alone.”  ― Elizabeth Gilbert, author

Early in the pandemic, I wrote of the unfortunate public health terminology of “social distancing” to describe the advice for physical distancing.  Indeed, if the data is any indication, the last thing our culture needed over the past few years (and before) was to become more socially isolated from each other. 

In fact, our cultural isolation has become so severe that in May of 2023 the US Surgeon General’s office under the leadership of Vivek Murthy, MD, published an advisory titled “Our Epidemic of Loneliness and Isolation.”  The advisory summarized the unprecedented levels of loneliness, disconnection, and isolation being experienced within our communities, and laid out a roadmap forward.

We healthcare professionals are not immune from this isolation and loneliness, though we often act (and are socialized to act) as if we are.  That is why the tag line for the PeerRxMed process is “No one should care alone.” 

Sure, there are times when we might desire some “alone time” (solitude), but just as often we may find ourselves “feeling so alone” (isolation) amid the challenges of our work.  Being able to differentiate between these two places on the “alone continuum” is essential for our professional well-being.

The picture below, titled “The Approaching Thunder Storm”, provides the opportunity for you to reflect on recent times when you “needed to be alone” contrasted with those times when you felt alone.  I encourage you to take some time this week to reflect on this, then reach out to your PeerRx partner to schedule some quarterly PRX90 time for some “live” connection (“up to 90 minutes every 90 days).  If you’re not participating in PeerRxMed or some similar process for intentional professional connection, now’s a wonderful time to start.  When I say “No one should care alone,” I really mean no one!

Click here to view a larger version (click on the image again at the website)

Reference:

• Martin Johnson Heade (1819-1904), Artist.  The Approaching Thunderstorm.  Oil on Canvas.  Displayed at The Metropolitan Museum of Art.  NY, NY.  Link

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org