DEREK RAGHAVAN, MD, PhD, FACP, FASCO, FRACP
I am pleased to respond to the Letter to the Editor from Davis and Wolinsky printed in this issue of The ASCO Post, disagreeing with my views about screening for prostate cancer.In brief, the key points of my commentary were as follows:
- PSA is a useful tool in the management of prostate cancer;
- Screening asymptomatic Caucasian males does not lead to improved overall survival; in the original reports from the randomized European Prostate Screening Trial, an increased death rate was documented in the most elderly group undergoing screening; several randomized trials of prostate screening have shown improved prostate-specific death rates but no improvement in overall length of survival;
- Screening for cancers of breast, colon, and lung does lead to improved tumor-specific and overall survival;
Those who support or oppose community-based routine screening for prostate cancer hold their views based on their understanding of the data;excellent people of good intent hold a contrary view.
In their letter, Davis and Wolinsky appear to have taken serious offense at a single line from a lengthy article that summarized the evidence for and against PSA screening: viz.“Some advocacy groups may have been influenced by the pharmaceutical industry providing them with potentially biased and rhetorical information.” They have focused on a very minor aspect of a much more serious discussion.They contend that this assertion is patronizing and false. I would like to agree with them, but then we would both be wrong.Having worked in health care for many decades, I really don’t think that there is any doubt that many domains within this industry are influenced inappropriately by marketing, lobbying, advertising, etc.; that single line was certainly not an attack on advocacy groups, nor did it suggest that all groups (or their advocates) fall under inappropriate influence.Similar to direct-to-patient marketing, advocacy groups are certainly targeted as influencers by constituencies within the pharmaceutical industry.I have no doubt that most advocacy groups do not fall prey to this, but this really was not an emphasis of my article.
As patient advocates, it would have been more productive for Davis and Wolinsky to address the data that I presented, and perhaps to discuss my suggestion of a potential solution that would lead to improved outcomes.There is no point in my discussion that proposes a “never screening” approach, but rather I emphasize a desire to see a concerted and collaborative approach to securing better data on which to base health policy decisions regarding screening.Also as patient advocates, it might have been helpful for Davis and Wolinsky to advocate for the groups who have not benefitted from the production of good PSA screening data—viz. African American males and men with a family history.Finally, it is never helpful to use unsourced data to support an extreme or rhetorical position.Their assertion that there has been a dramatic increase in patients presenting with metastatic prostate cancer over the decades simply is not supported by carefully constructed data from another cancer advocacy group.In 2000, 8% of patients presented with metastatic prostate cancer, according to the American Cancer Society (ACS);1in 2024, 8% of patients presented with metastatic prostate cancer, according to the ACS Cancer Statistics.2Similarly published trials have proven that T2 tumors can be cured, in contrast to their inaccurate claim.
The discussion about screening for prostate cancer should not be framed in an artificially polemical stance, but rather focused on dispassionate assessment of the available structured data, with a focus on optimizing health policy for the benefit of patients.Resources for health care are not unlimited and we need to be sure that the very expensive PSA screening strategy provides true benefit to the community. The strategy that I proposed at the end of my article could hopefully lead to the target that Davis and Wolinsky seek—a more accurately focused strategy of screening.
DISCLOSURE: Dr. Raghavan reported no conflicts of interest.
REFERENCES
1. Greenlee RT, Murray T, Bolden S and Wingo PA:Cancer statistics 2000.CA Cancer J Clin 50:7-33, 2000.
2. Siegel RL, Giaquinto AN, Jemal A:Cancer statistics 2024.CA Cancer J Clin 74:12-49, 2023.
Dr. Raghavan is an oncologist at the Veterans Administration Health Care Center, Charlotte; Emeritus Professor at Wake Forest School of Medicine; and External Advisor at Henry Ford Health and Michigan State University Cancer Collaboration.
