醫師持續發現PSA檢測的優點


  【24drs.com】在最近的調查中,雖然大約五分之二的醫師(42%)表示,他們認為前列腺特異抗原(PSA)檢測被過度使用,但是絕大多數(90%)醫師認為檢測之益總是/通常/有時大於風險,許多醫師經常建議他們的男性患者進行基線診斷。
  
  這項調查結果反映出,在美國預防醫學工作小組的2012年篩檢建議將PSA檢測定為「D級」之後,PSA檢測已經變成地雷區。
  
  2015年發表於JAMA期刊的兩篇研究(一篇使用「流行病監測及最終結果(Surveillance, Epidemiology and End Results)」計畫的資料,另一篇使用「國民健康訪問調查(National Health Interview Survey)」的資料)顯示,在USPSTF提出建議後一年,以PSA檢測篩檢前列腺癌的使用率下降。當時,作者們表示,不清楚篩檢減少是否會導致更多癌症被遺漏或死亡率上升。
  
  最近有一篇研究發表於2016年11月JAMA Surgery期刊,批判USPSTF造成自2012年以來前列腺切片和根治性前列腺切除術的顯著下降,USPSTF目前正在重新審查PSA篩檢指引,並於2016年5月發佈了最終研究計畫。
  
  調查顯示,儘管有爭議,醫師們依舊建議他們的男性患者進行基線PSA檢測,當被問及他們建議這種基線檢測的頻率時,680位受訪者中約有四分之一(26%)表示「總是會」、61%表示「通常」或「有時候」敦促基線檢測,只有少數醫師表示他們 「很少」或「從不」建議PSA。
  
  家庭醫學專家Jan Sheringham醫師對這項調查發表評論指出,它只有透過追蹤已知的早期基線變化,而沒有[良性前列腺增生]等等干擾,我們可以幫助我們的患者對他們的照護做出明智決定,包括觀察等待、主動監測或確定的醫療。她寫道,是的,沒有傷害是我們的箴言,但我相信,根據我們目前的知識,如果不做適當的檢測,我們實際上會造成傷害。
  
  參加調查的內科醫師和家庭醫學醫師對PSA檢測的熱情似乎比泌尿科醫師低,但仍然接受診斷。有比較多(14%)的泌尿科醫師表示,檢測的好處總是超過風險,而有9%的內科醫師與11%的家庭醫學醫師如此認為。41%的泌尿科醫師表示,檢測的好處通常超過風險,而有26%的內科醫師與30%的家庭醫學醫師如此認為。
  
  約三分之一(30%)的泌尿科醫師表示,他們總是會建議進行基線PSA,而有21%的內科醫師與21%的家庭醫學醫師如此。血液科/腫瘤科醫師的反應相似,有21%表示他們總是會敦促基線檢測;超過半數(59%)表示他們只是有時候建議。
  
  腫瘤科James Benton醫師對這項調查發表評論時表示,使用PSA和[直腸指檢]篩檢前列腺癌是相當無害的,它只需要一次驗血和一個非常簡短的檢查。
  
  Benton醫師表示,篩檢不是問題。如何運用這些資訊才是真正的問題。醫療官員不應該是篩檢或不篩檢之決定的仲裁者,患者與他的家人和醫師應有未受阻礙之權利知道他是否罹患癌症,並就如何進行各種治療選項(主動監視、放射或手術)做出明智決定。
  
  家庭醫師Chris Blair表示,對於PSA檢測的適當平衡點,或許只是時間問題。
  
  他寫道,不久以前,PSA的使用增加,導致熱心的外科醫師進行手術切除。Blair醫師表示,現在,觀察等待和監視、以及其他復雜的診斷,都被納入討論中。
  
  希望我們從變動局勢中學習,讓世界變得更美好。
  
  資料來源: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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