A few observations on the PSA testing debate

Much has and will be written on the new US Preventive Services Task Force (USPTF) recommendations against routine use of the prostate specific antigen (PSA) blood test in healthy men .

I’m not a doctor or scientist and have not had the PSA test or a subsequent biopsy myself, but I am a close observer of the health care system. Two key takeaways for me are:

  • The USPTF should have issued the PSA guidelines before it issued the screening mammography guidelines
  • A substantial, positive effect of the new guidelines will be to empower patients and families to take a more active role in their care, which will counterbalance some of the bias toward unnecessary treatment that currently characterizes the system

Let me explain:

It appears the USPTF put off the PSA decision after the firestorm of criticism ignited by its 2009 recommendation to reduce the use of screening mammography on younger women. In my estimation the leading reason for all the fuss two years ago was that while it was easy to identify people whose lives may have been saved by screening mammography, it was harder –though far from impossible—to identify people who’d been harmed. In addition, a whole movement had been built through the joint efforts of patient activists and commercial interests, with increases in screening mammography rates held up as an explicit goal. And finally, the issue of breast cancer is inextricably connected with the empowerment of women and access to the health care system.

PSA screening is different. No one thinks PSA is a great test: the high rates of false positives and false negatives are widely acknowledged. Watchful waiting is an accepted practice. Many patients understand that treatment involves serious tradeoffs, especially the strong possibility of incontinence and impotence. People are learning that biopsies have their own challenges, such as the possibility of blood in the semen for weeks afterwards. Many people who get prostate cancer die of something else.  Finally access to PSA testing is not connected with any male empowerment movement that I’m aware of.

If the Task Force had issued the PSA recommendation first it would have given people an opportunity to discuss and debate some of the central issues and nuances of screening without so many of the distractions. Maybe that would have cleared the way for a more thoughtful discourse on screening mammography.

I thought the New York Times did a great job of laying out the range of reactions in its letters section today:

  • An academic oncologist points out that the PSA blood test doesn’t cause impotence or incontinence and that 30,000 men die of prostate cancer in the US annually. His solution: use the test, but carefully, and have doctor and patient work together to decide course of action. I agree.
  • The wife of a man treated for prostate cancer points out the “terrible toll” of treatments and says the only benefit is to the medical/industrial complex. I generally agree, but she goes too far in ascribing PSA testing solely to financial interests.
  • An academic urologist argues its irresponsible to reject PSA based on 10 year follow-up data, when 20 years is more appropriate. He may have a point, but he neglects any mention of the harm of false positives.
  • A man who had a positive biopsy after his PSA spiked underwent radiation treatment and recovered with minimal side effects. He’s outraged by the recommendation to stop PSA. Hard to argue, and he should count himself among the lucky.
  • A urologist suggests “rationing” (his words) by banning Medicare from paying for screening of men over 75 or 80 when it pretty clearly does more harm than good. His letter is perhaps the best, and he is the only one of the writers who steps outside his own self-interest to make a broader point.

As people read this range of strongly held, but complementary views I feel confident many will be in a better position to make informed decisions in their particular situations.


October 11, 2011

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