October 9, 2011

The U.S. Preventative Services Task Force’s draft report published Friday recommends against routine use of the PSA test that has been available for the last 17 years and has helped diagnose prostate cancer, often in its earliest stage.  Anytime an individual professes to be wiser than the U.S. Preventative Services Task Force, he opens himself up to criticism and the suggestion that he suffers from delusions of grandeur.

I assure you; I have no delusions of grandeur.  However, I do not understand the panel’s conclusion that PSA not be a part of a routine screening exam.  According to an article in the Chicago Tribune, “The task force wasn’t trying to figure out whether screening for elevated levels of a protein called prostate-specific antigen would save lives; the answer to that is yes.”  I’m confused. Isn’t the whole purpose of screening test to “save” lives? 

The Tribune article went on to say, “the question before the panel was whether PSA testing saves enough lives to justify the considerable medical fallout, including loss of urinary control and impotence of men who may not have needed to undergo treatment.”  In other words, what are the financial, physical, and emotional costs of treating prostate cancer; and what are the costs of not treating it?  In order to answer such a lofty question, the panel needs to define how many lives are “enough lives” to warrant a screening test.  If the answer is one life, mine or yours, then the screening test is valid.

The panel weighs the emotional and physical results of treating prostate cancer heavily in making their recommendation.  Why?  I believe the answer is that PSA testing and the resultant “medical fallout” is financially expensive and that basing their opinion on the financial aspect of “medical fallout” would be seen as rationing.  Rationing is a dirty word.  It is much easier to target physical side effects like urinary incontinence and impotence.  To the best of my knowledge, patients who die from prostate cancer (corpses) are incontinent of urine and impotent.

PSA tests are by no means perfect.  There are false positives (test is positive despite the fact that the patient does not have cancer) and false negatives (test is negative and patient has cancer).  For this reason, one elevated PSA test is hard to interpret.  A series or trending of PSA tests over many years helps increase the diagnostic value of the test.  There is a “Catch 22” at play here.  If you don’t order “A” (the first) PSA, you can’t have a series of PSA, to help you diagnose an early cancer.

Complicating things even more is the fact that there are slow growing prostate cancers which are relatively harmless and rapidly progressive cancers that are often lethal.  Early diagnosis saves lives!  What would happen if we stopped screening and waited for prostate cancer to show itself?  I’m afraid we are about to find out!

According to the Tribune article, “Between 20 – 30% of men who have surgery and radiation wind up with erectile dysfunction, urinary incontinence and other adverse effects.”  These statistics are probably true, although the introduction of the DiVinci Robotic surgical device and new techniques in radiation therapy may well improve these statistics.  The addition of post-op physical therapy improves continence, as well.

So, what does this new edict from our government mean?  One thing that will happen immediately is that Medicare and insurance companies will stop paying for PSA testing, deeming it unnecessary.  (Once again the insurers are given a sweet gift.)  A second result will be that many men will decide not to have PSA testing, either due to the new, out of pocket expense or the fear of “medical fallout” sited by the Panel. 

Unfortunately, we are about to find out what the natural history of undiagnosed prostate cancer is.  Digital rectal exams are not good at finding prostate cancer in its early stages but will certainly diagnose cancer when a mass has replaced your normal prostate tissue.   When a mass is found on digital rectal exam, a diagnostic PSA will be obtained, not to diagnose prostate cancer, but instead to follow the success or failure of treatment.

Once again, Big Brother has decided to “protect” us from ourselves and to decide how many lives are “enough lives” to warrant a screening test.  I think each patient should have the right to decide whether a PSA screening is right for him and I will continue to offer the test.  I will continue to help those patients found to have prostate cancer, at an early stage, find the treatment that is best for them.  I will arm my patients with the knowledge of the risks and benefits of each and every treatment option available to them (including watchful waiting).

Those patients and doctors who choose to follow the new recommendations are opting for the “blindly waiting” option.  Life is a gamble.  The U.S. Preventative Services Task Force’s job should be to help us find the game with the best odds for a win.  Unfortunately, I suspect that financial concerns weigh heavily in their decisions, skewing their findings.