Paciente de 27 años, con síndrome nefrótico por amiloidosis renal secundaria a Enfermedad de Crohn, remitido a urgencias por malestar general, vómitos y diarrea de 10 días de evolución.
El paciente mantenía hasta este cuadro función renal estable con Crs: 2-2 5 mg/dL, y mantenía tratamiento crónico con esteroides. 10 días antes de su ingreso el paciente comenzó con síndrome febril y diarrea sanguinolenta (6-7 deposiciones/día), y vómitos ocasionales. A su llegada urgencias el paciente estaba en muy mala situación clínica. Respiración de Kussmaul, mal perfundido y signos de deshidratación. TA: 90/60. Frecuencia: 130 lpm. Intensa palidez cutáneo-mucosa. Hábito asténico. El resto de la exploración física fue anodina
Andrew Buelt, DO, and Joe Weatherly, DO, are family medicine residents in St. Petersburg, Fla. Together, they co-produce the podcast Questioning Medicine, where they deconstruct issues confronting today's clinicians. In this guest blog, Buelt gives his take on the overuse of prostate cancer screenings
Let the Prostate Be
As prostate cancer awareness month just ended, prostate cancer screening seemed a fitting subject for this week's blog.
Those who know the evidence might think this argument pits European practices against our own domestic actions. Almost like a Ryder Cup for prostate screening. However, I recently saw that almost 50% of patients admit to undergoing lubed finger insertions and blood tests, which we know to be fairly inaccurate, in the last 12 months.
In a Research Letter in JAMA Internal Medicine by Sammon et al., the fact that so many physicians are still screening for prostate cancer makes my evidence-based medicine soul cringe. In a 2012 survey, the authors found that among 114,544 respondents, 37% had undergone screening. Higher socioeconomic status nearly doubled a man's odds of being screened (odds ratio 1.91, 95% CI 2.69-3.34).
I suppose some physicians will try to argue that rectal exams are not unpleasant or uncomfortable for the patient, as many did in the comments section of my pelvic exam post. However, if you really believe that, it's probably been a while since your last rectal exam.
The Screening Process
There are two parts to prostate screening: the digital rectal exam (DRE) and the prostate-specific antigen (PSA) blood test. Guided by evidence, here's a look at harms and benefits.
First, is the index finger so sensitive and accurate that it can really detect cancer with the DRE? A little common sense would tell us "no chance," and the evidence seems to support that.
In a study published in the Annals of Surgical Oncology by Richie et al., among 644 asymptomatic men, 241 had an abnormal DRE or elevated PSA. And of the 163 who underwent further ultrasound or biopsy, 77% were found to have normal results.
In a study published in the Journal of the National Cancer Institute, which reported the results of The Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, Andriole et al. found barely any benefit with PSA screening and DRE. The cumulative mortality rates in the intervention arm were 3.7 compared to 3.4 per 10,000 person-years in the control arm.
Authors of the European Randomized Study of Screening for Prostate Cancer (ERSPC) found a 20% reduction in prostate cancer deaths with PSA. Yet, when you look at actual numbers, it paints a much different picture. The ERSPC study estimated that 1,410 men would need to undergo screening, and 48 more cases of prostate cancer would need to be treated, for one life to be saved. Meaning 48 men will possibly endure erectile dysfunction or urinary incontinence for life, for every one life saved.
I'll repeat the most important part of that rant: one out of a thousand is saved! At least 50 men will have a serious complication and about 100 will have to undergo anxiety and sleepless nights for a disease they don't even have.
The problem is the very small or almost nonsignificant increase in mortality. I do not care if my patient survives longer with a disease, as long as the age of mortality remains the same.
After all, the reason we treat hypertension, high cholesterol, or screen for cancer is to have people live longer; not to die at the same age.
Of course, there are physicians out there with anecdotal evidence of catching life-threatening prostate cancer in early stages during a routine DRE or PSA, and will therefore insist they are great tests, just like the pelvic exam.
What shouldn't be forgotten is all of the men who now wear a diaper, can't get an erection, or can't sleep from high anxiety.
Thus, instead of one out of 1,000, it is 2.5 out of 1,000. At that point, it might be worth at least a conversation. It is also decent to trend the success of prostate cancer treatment. However, as a screening tool it's like swimming with a shark: rarely will it kill you, but it will likely to leave you mentally or physically scarred, feeling vulnerable, and with high anxiety.