- Email: [email protected]
Re: Quality-of-life Effects of Prostate-specific Antigen Screening
180
EUROPEAN UROLOGY 63 (2013) 178–182
Re: Quality-of-life Effects of Prostate-specific Antigen Screening Heijnsdijk EA, Wever EM, Auvinen A, et al. N Engl J Med 2012;367:595–605 Expert’s summary: This report used decision modeling to quantify how the benefits of prostate cancer (PCa) screening is counterbalanced by the harms. The authors used data from the European Randomized Study of Screening for Prostate Cancer to predict outcomes under various scenarios. They report that annual screening of men aged 55–69 yr would result in a 28% decrease in PCa deaths, a 35% decrease in palliative treatments, and a total of 73 life-years gained per 1000 men screened (average 8.4 yr per death avoided). However, they discounted the gain by 23% because of offsetting treatment complications, that is, the gain was 56 quality-adjusted life-years (QALYs). To prevent one death, 98 men must be screened and five cancers detected. Screening men aged 55–74 yr resulted in 82 lifeyears gained but the same 56 QALYs.
that most patients will gain from screening because we do not know how many have lower versus higher utilities. If we knew that all have utilities consistent with a gain, then we could recommend universal screening. The US Preventive Services Task Force has recommended against screening in all men [5]. Sox stated that until we know the distribution of utilities for all health states, guidelines should avoid recommending for or against PSA screening but rather should recommend a shared decision process that includes assessing patients’ feelings about what they could go through after screening. In other words, the task force was wrong to downgrade the PSA screening recommendation. Conflicts of interest: The author has received research support and honoraria for speaking from and been an investigator for BeckmanCoulter Inc., has received research support and royalties as co-inventor from and been an investigator and consultant for OHMX Inc., has received research support from and been an investigator for deCODE genetics Inc., and has been an investigator for Nanosphere.
References Expert’s comments: If assumptions used in decision modeling are invalid, they fail to predict reality. Based on European data, the authors assumed that 43% of cancers were overdiagnosed. This is higher than estimates from US models (23–28% [1]) or surgical data (7–20% [2,3]). The authors attempt to quantify the trade-offs by expressing both benefits and harms in life-years. Sox’s accompanying editorial points out that this is like comparing apples and oranges [4]. The years gained by avoiding a PCa death is an objective assessment, but conversion of how a man feels about the number of years of life he would trade to avoid possible future complications he has never experienced (utilities) remains subjective. The cold truth is that it is easier said than done: ‘‘Would you rather live for 6 years with normal continence or for 14 years with a 10% chance of having to wear a pad? How about 7 versus 13?’’ Sox cautioned that the utilities assigned were the least satisfactory aspect of the report and that we cannot conclude
Re: Treatment of Adults with Complications from Previous Hypospadias Surgery Myers JB, McAninch JW, Erickson BA, Breyer BN J Urol 2012;188:459–63 Expert’s summary: The authors looked at a database of 1127 patients who had undergone urethroplasty at a single institution by a single surgeon between 1980 and 2009. From this database, they did a retrospective review of 50 urethroplasty patients who had undergone previous hypospadias surgery and were >18 yr of age. Of the 50 men presenting with complications, 78% had undergone hypospadias surgery during childhood and 66% had multiple previous surgeries. The most common complications seen in this group were urethral stricture in 72% and urethral cutaneous fistula in 24%.
[1] Draisma G, Etzioni R, Tsodikov A, et al. Lead time and overdiagnosis in prostate-specific antigen screening: importance of methods and context. J Natl Cancer Inst 2009;101:374–83. [2] Pelzer AE, Bektic J, Akkad T, et al. Under diagnosis and over diagnosis of prostate cancer in a screening population with serum PSA 2 to 10 ng/ml. J Urol 2007;178:93–7. [3] Graif T, Loeb S, Roehl KA, et al. Underdiagnosis and over diagnosis of prostate cancer. J Urol 2007;178:88–92. [4] Sox HC. Quality of life and guidelines for PSA screening. N Engl J Med 2012;367:669–71. [5] Moyer VA, US Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2012;157:120–34. William J. Catalona Northwestern Medical Faculty Foundation, Chicago, IL, USA E-mail address: [email protected]. http://dx.doi.org/10.1016/j.eururo.2012.10.030
The authors presented a well-organized and thoughtful approach to the management of the various complications, depending on the site of the urethral stricture and the quality of the surrounding tissues. Despite this wellorganized approach, their initial success rate in the 50 individuals was only 50%; of the other 50%, half developed recurrent urethral stricture and half developed urethral cutaneous fistula. The conclusion drawn by the authors is that patients with complications following previous hypospadias repair must be committed to the possibility of several surgeries to manage long-term urethral problems. Expert’s comments: As more pediatric patients who have undergone hypospadias repair during childhood transition to adolescence and adulthood, it has become clear that what is initially considered a
EUROPEAN UROLOGY 63 (2013) 178–182
Re: Quality-of-life Effects of Prostate-specific Antigen Screening Heijnsdijk EA, Wever EM, Auvinen A, et al. N Engl J Med 2012;367:595–605 Expert’s summary: This report used decision modeling to quantify how the benefits of prostate cancer (PCa) screening is counterbalanced by the harms. The authors used data from the European Randomized Study of Screening for Prostate Cancer to predict outcomes under various scenarios. They report that annual screening of men aged 55–69 yr would result in a 28% decrease in PCa deaths, a 35% decrease in palliative treatments, and a total of 73 life-years gained per 1000 men screened (average 8.4 yr per death avoided). However, they discounted the gain by 23% because of offsetting treatment complications, that is, the gain was 56 quality-adjusted life-years (QALYs). To prevent one death, 98 men must be screened and five cancers detected. Screening men aged 55–74 yr resulted in 82 lifeyears gained but the same 56 QALYs.
that most patients will gain from screening because we do not know how many have lower versus higher utilities. If we knew that all have utilities consistent with a gain, then we could recommend universal screening. The US Preventive Services Task Force has recommended against screening in all men [5]. Sox stated that until we know the distribution of utilities for all health states, guidelines should avoid recommending for or against PSA screening but rather should recommend a shared decision process that includes assessing patients’ feelings about what they could go through after screening. In other words, the task force was wrong to downgrade the PSA screening recommendation. Conflicts of interest: The author has received research support and honoraria for speaking from and been an investigator for BeckmanCoulter Inc., has received research support and royalties as co-inventor from and been an investigator and consultant for OHMX Inc., has received research support from and been an investigator for deCODE genetics Inc., and has been an investigator for Nanosphere.
References Expert’s comments: If assumptions used in decision modeling are invalid, they fail to predict reality. Based on European data, the authors assumed that 43% of cancers were overdiagnosed. This is higher than estimates from US models (23–28% [1]) or surgical data (7–20% [2,3]). The authors attempt to quantify the trade-offs by expressing both benefits and harms in life-years. Sox’s accompanying editorial points out that this is like comparing apples and oranges [4]. The years gained by avoiding a PCa death is an objective assessment, but conversion of how a man feels about the number of years of life he would trade to avoid possible future complications he has never experienced (utilities) remains subjective. The cold truth is that it is easier said than done: ‘‘Would you rather live for 6 years with normal continence or for 14 years with a 10% chance of having to wear a pad? How about 7 versus 13?’’ Sox cautioned that the utilities assigned were the least satisfactory aspect of the report and that we cannot conclude
Re: Treatment of Adults with Complications from Previous Hypospadias Surgery Myers JB, McAninch JW, Erickson BA, Breyer BN J Urol 2012;188:459–63 Expert’s summary: The authors looked at a database of 1127 patients who had undergone urethroplasty at a single institution by a single surgeon between 1980 and 2009. From this database, they did a retrospective review of 50 urethroplasty patients who had undergone previous hypospadias surgery and were >18 yr of age. Of the 50 men presenting with complications, 78% had undergone hypospadias surgery during childhood and 66% had multiple previous surgeries. The most common complications seen in this group were urethral stricture in 72% and urethral cutaneous fistula in 24%.
[1] Draisma G, Etzioni R, Tsodikov A, et al. Lead time and overdiagnosis in prostate-specific antigen screening: importance of methods and context. J Natl Cancer Inst 2009;101:374–83. [2] Pelzer AE, Bektic J, Akkad T, et al. Under diagnosis and over diagnosis of prostate cancer in a screening population with serum PSA 2 to 10 ng/ml. J Urol 2007;178:93–7. [3] Graif T, Loeb S, Roehl KA, et al. Underdiagnosis and over diagnosis of prostate cancer. J Urol 2007;178:88–92. [4] Sox HC. Quality of life and guidelines for PSA screening. N Engl J Med 2012;367:669–71. [5] Moyer VA, US Preventive Services Task Force. Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2012;157:120–34. William J. Catalona Northwestern Medical Faculty Foundation, Chicago, IL, USA E-mail address: [email protected]. http://dx.doi.org/10.1016/j.eururo.2012.10.030
The authors presented a well-organized and thoughtful approach to the management of the various complications, depending on the site of the urethral stricture and the quality of the surrounding tissues. Despite this wellorganized approach, their initial success rate in the 50 individuals was only 50%; of the other 50%, half developed recurrent urethral stricture and half developed urethral cutaneous fistula. The conclusion drawn by the authors is that patients with complications following previous hypospadias repair must be committed to the possibility of several surgeries to manage long-term urethral problems. Expert’s comments: As more pediatric patients who have undergone hypospadias repair during childhood transition to adolescence and adulthood, it has become clear that what is initially considered a