“I don’t know if prostate screening saves lives,” he said. “But it sure sells diapers.”
6-11-12 Houston Chronicle
The recommendation that men no longer routinely be screened for prostate cancer has prompted a backlash from some doctors, who suggest the shift could reverse a 20-year trend that has dropped death rates from the disease by 40 percent.
Other groups say the resistance illustrates the difficulty of changing lucrative financial models as well as long-established habits in American medicine.
“It’s a huge economic issue,” said Dr. Otis Brawley, chief medical officer for the American Cancer Society, who notes that free prostate screening programs can be a financial boon for hospitals as people with high PSA scores come in for treatment. “People are making money hand over fist on this.”
The PSA test, a blood test for prostate-specific antigen, has become an annual ritual for an estimated 20 million men, most of them over 50. The American Cancer Society estimates 241,740 new cases of prostate cancer will be diagnosed in the United States this year.
The test alone can’t determine who has prostate cancer. Men with high PSA levels are referred for a biopsy.
The issue is controversial because many prostate cancers are slow-growing and the risks of treatment – including incontinence and impotence – can outweigh the benefits.
Count Brawley among those who believe the test launches men into a torrent of treatment and often miserable side effects, whether they would have suffered problems from the cancer or not.
“I don’t know if prostate screening saves lives,” he said. “But it sure sells diapers.”
Most diagnosed early
The recommendation last month by the U.S. Preventive Services Task Force to end routine screening drew sharp rebuttals. The American Urological Association called it “inappropriate and irresponsible.”
Dr. Elise Cook, an associate professor in the department of clinical cancer prevention at the University of Texas M.D. Anderson Cancer Center, said the test isn’t for all men. M.D. Anderson doesn’t recommend uniform screening.
But Cook said all men over age 50 – 45 for those at higher risk, such as African-Americans – should discuss the risks and benefits with their doctor.
Cook focuses on a common concern of the pro-screening forces – before widespread PSA screening, prostate cancer often wasn’t diagnosed until it had spread beyond the prostate, a walnut-sized gland between the bladder and the penis.
Most cases now are diagnosed early.
And although Cook said early screening may not deserve all the credit for the 40 percent drop in deaths from prostate cancer – treatment has improved, too – she said less screening could result in more disease that spreads.
A broader shift
The uproar over PSA screening is just the latest symptom of a broader shift in medicine.
“I think this is what you are going to see increasingly in cancer screening,” said Dr. Evelyn Chan, associate professor of internal medicine at The University of Texas Health Science Center at Houston. “It’s getting more nuanced, more complicated.”
The Preventive Services Task Force stopped short of saying no man should ever have a PSA test. It said men who want to be screened should be informed of the risks.
Men have to consider their personal risk factors, as well as their tolerance for living with risk, Chan said. She also recommends they be aware of their doctor’s bias toward the test.
She co-authored a 2005 study that found 87 percent of male physicians 50 and older reported having had a PSA exam. That increased to 95 percent for urologists.
“If the test is already so widely used by doctors themselves, there’s going to be a bias toward testing their own patients,” she said. “It’s difficult for doctors to suddenly change their practice on the recommendation of one group.”
Change is hard
And change is hard, said Dr. Howard Brody, director of the Institute for the Medical Humanities at the University of Texas Medical Branch at Galveston.
“This idea of talking to patients has always had resistance from medicine,” he said. “(The fear is) if you tell people there could be risks, they won’t do what they need to.”
The risk doesn’t come from drawing blood for the test. It’s everything that comes after.
“The harm comes from the cascade,” Brody said. “Once you get a test result, certain things are going to happen if the result is positive. Information is not harmless.”
Editor’s Note: Recommended reading – “The Last Well Person”
