医师持续发现PSA检测的优点


  【24drs.com】在最近的调查中,虽然大约五分之二的医师(42%)表示,他们认为前列腺特异抗原(PSA)检测被过度使用,但是绝大多数(90%)医师认为检测之益总是/通常/有时大于风险,许多医师经常建议他们的男性患者进行基线诊断。
  
  这项调查结果反映出,在美国预防医学工作小组的2012年筛检建议将PSA检测定为「D级」之后,PSA检测已经变成地雷区。
  
  2015年发表于JAMA期刊的两篇研究(一篇使用「流行病监测及最终结果(Surveillance, Epidemiology and End Results)」计画的资料,另一篇使用「国民健康访问调查(National Health Interview Survey)」的资料)显示,在USPSTF提出建议后一年,以PSA检测筛检前列腺癌的使用率下降。当时,作者们表示,不清楚筛检减少是否会导致更多癌症被遗漏或死亡率上升。
  
  最近有一篇研究发表于2016年11月JAMA Surgery期刊,批判USPSTF造成自2012年以来前列腺切片和根治性前列腺切除术的显著下降,USPSTF目前正在重新审查PSA筛检指引,并于2016年5月发布了最终研究计画。
  
  调查显示,尽管有争议,医师们依旧建议他们的男性患者进行基线PSA检测,当被问及他们建议这种基线检测的频率时,680位受访者中约有四分之一(26%)表示「总是会」、61%表示「通常」或「有时候」敦促基线检测,只有少数医师表示他们 「很少」或「从不」建议PSA。
  
  家庭医学专家Jan Sheringham医师对这项调查发表评论指出,它只有透过追踪已知的早期基线变化,而没有[良性前列腺增生]等等干扰,我们可以帮助我们的患者对他们的照护做出明智决定,包括观察等待、主动监测或确定的医疗。她写道,是的,没有伤害是我们的箴言,但我相信,根据我们目前的知识,如果不做适当的检测,我们实际上会造成伤害。
  
  参加调查的内科医师和家庭医学医师对PSA检测的热情似乎比泌尿科医师低,但仍然接受诊断。有比较多(14%)的泌尿科医师表示,检测的好处总是超过风险,而有9%的内科医师与11%的家庭医学医师如此认为。41%的泌尿科医师表示,检测的好处通常超过风险,而有26%的内科医师与30%的家庭医学医师如此认为。
  
  约三分之一(30%)的泌尿科医师表示,他们总是会建议进行基线PSA,而有21%的内科医师与21%的家庭医学医师如此。血液科/肿瘤科医师的反应相似,有21%表示他们总是会敦促基线检测;超过半数(59%)表示他们只是有时候建议。
  
  肿瘤科James Benton医师对这项调查发表评论时表示,使用PSA和[直肠指检]筛检前列腺癌是相当无害的,它只需要一次验血和一个非常简短的检查。
  
  Benton医师表示,筛检不是问题。如何运用这些信息才是真正的问题。医疗官员不应该是筛检或不筛检之决定的仲裁者,患者与他的家人和医师应有未受阻碍之权利知道他是否罹患癌症,并就如何进行各种治疗选项(主动监视、放射或手术)做出明智决定。
  
  家庭医师Chris Blair表示,对于PSA检测的适当平衡点,或许只是时间问题。
  
  他写道,不久以前,PSA的使用增加,导致热心的外科医师进行手术切除。Blair医师表示,现在,观察等待和监视、以及其它复杂的诊断,都被纳入讨论中。
  
  希望我们从变动局势中学习,让世界变得更美好。
  
  资料来源:http://www.24drs.com/
  
  Native link:Physicians Continue to See Merits of PSA Testing
  

Physicians Continue to See Merits of PSA Testing

By Alicia Ault
Medscape Medical News

Although about two fifths of all of physicians (4%) in a recent Medscape poll said they believe the prostate specific antigen (PSA) test is overused, a huge majority (90%) said the benefits of the test always, often, or sometimes outweigh the risks, and many frequently recommend a baseline diagnostic for their male patients.

The poll results reflect the minefield that PSA testing has become in the wake of the US Preventive Services Task Force's 2012 recommendation against screening. The agency gave PSA testing a "D" rating.

Two studies subsequently published in JAMA in 2015 — one using data from the Surveillance, Epidemiology and End Results program, and the other using National Health Interview Survey data ─ showed that prostate cancer screening using the PSA test had declined in the year after the USPSTF recommendation. At the time, the authors said it wasn't clear whether the decrease in screening had contributed to more cancers being missed or a rise in mortality.

A more recent study published in JAMA Surgery in November 2016 blamed the USPSTF for a significant decline in prostate biopsies and radical prostatectomies since 2012. The USPSTF is currently revisiting the PSA screening guideline and issued a final research plan in May 2016.

Baseline Testing Embraced

The Medscape poll showed that despite the controversy, physicians are still recommending baseline PSA testing to their male patients. When asked how often they recommend such a baseline test, almost a quarter (26%) of the poll's 680 respondents said "always," while 61% said they "often" or "sometimes" urge the baseline. Only a small percentage of doctors said they "rarely" or "never" recommended a baseline PSA.

"It is only by following the changes from a known early baseline without interference from [benign prostatic hyperplasia] etc that we can assist our patients to make informed decisions about their care, including watchful waiting, active surveillance, or definitive Mx," said Dr Jan Sheringham, a family medicine specialist, in comments on the poll. "Yes, do no harm is our watchcry, but I believe we can actually cause harm by not doing this test appropriately and according to our current knowledge," she wrote.

Internists and family practice specialists who took the poll seemed a tad less enthusiastic than urologists about PSA testing, but still embraced the diagnostic. Slightly more urologists said the benefits of testing "always" outweigh the risks — 14%, compared with 9% of internists and 11% of family medicine physicians. Forty-one percent of urologists said testing's benefits "often" outweigh risks, compared with 26% of internists and 30% of family medicine specialists.

About a third (30%) of urologists said they "always" recommend a baseline PSA, compared with 21% of internal medicine specialists and 21% of family medicine doctors. Colleagues in hematology/oncology responded similarly, with 21% saying they always urge the baseline; more than half (59%) said they only "sometimes" recommend it.

"Screening for prostate cancer with a PSA and a [digital rectal exam] is fairly innocuous, and it entails only a blood test, and a very brief exam," said James Benton, MD, an oncologist, in commenting on the poll.

Dr Benton said screening is not the issue. "It is what one does with the information that is the real issue," he said. "Medical bureaucrats should not be the arbiters of decisions to screen or not screen," said Dr Benton, adding, "A man in conjunction with his family and doctor should have an unobstructed right to know if he has a cancer and make an informed decision as to how he will proceed with various treatment options ─ from active surveillance, radiation, or surgery."

General practice physician Chris Blair said it was perhaps just a matter of time before the proper balance was found with PSA testing.

"Not so long ago, an increased PSA often lead to surgical removal by enthusiastic surgeons," he wrote. "Now watchful waiting and surveillance, with other sophisticated diagnostics, is included in the discussion," said Dr Blair.

"The pendulum oscillates from one extreme to another, and hopefully we learn, and the world becomes a better place."

    
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