USPSTF – It’s About Time

May 22, 2012

The numbers are stark. According to the United States Preventive Services Task Force, for every man whose death from prostate cancer is prevented through PSA screening, 40 become impotent or suffer incontinence problems, two have heart attacks and one a blood clot. Then there’s the psychological harm of a “false positive” test result, which is 80 percent of all “positive” tests. They lead to unnecessary worry, follow-up biopsies, physical discomfort and even harm. Final grade: D.

Three men close to me have been diagnosed with prostate cancer late in life. Each was around 70. My dad, already in throes of advancing Alzheimer’s disease, did what the doctor ordered (actually, I suspect my mom told my dad to do what the doctor ordered). He had surgery. And for the last six years of his life, which until his final three months was at home, she cleaned up after him because of his incontinence. My neighbor made the same choice. He quietly admitted to me one day that he suffers from similar symptoms, but he is grateful because he believes his life was saved by the operation. And my friend Arnie? I’ve written about him in this space before. He was diagnosed at 70, and being a psychiatrist with a strong sense of his own sexual being, understood the potential tradeoffs. He decided to forgo treatment. He died a few years ago at 90. I never learned the cause.

So what does it mean that PSA testing gets a D rating? If you want the test, or your doctor performs it routinely, your insurance company may not pay for the test. It won’t have to since the Affordable Care Act says prevention services must be rated either A or B to warrant automatic coverage. Yet I wouldn’t worry if you’re a symptomless man who is hellbent on getting this unnecessary test. Three insurers told the Washington Post yesterday that they will continue to pay for the test if it is ordered by a physician. I can’t imagine Medicare cutting off payment, either. The wary bureaucrats at CMS have no interest in wading into a fight with the “Evidence? We don’t need no stinkin’ evidence” crowd.

I predict that you’ll see no change in clinical medical practice from this pronouncement by USPSTF. Physicians in community practice will continue to routinely screen men between 50 and 75. Millions will continue to receive unnecessary treatment. A few thousand lives each year will be saved. Will that justify the harm — including premature deaths — caused by the false positives? We’ll never know. Because those who experience those harms will suffer in silence. After all, they’re men.

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One Response to USPSTF – It’s About Time

  1. Greg Pawelski on May 22, 2012 at 9:27 am

    I had mentioned this before. I was well aware that myelodysplastic syndrome (MDS) can be caused by treatment with chemotherapy. I was rudely reminded that radiation therapy can cause it too (treatment-related MDS or secondary MDS). Treatment-related MDS is often more severe and diffult to treat than de novo MDS (unknown changes to the bone marrow).

    I lost my brother-in-law (my wife’s brother) to MDS after he received permanent seed implants for “early” prostate cancer treatment (he was in his ’70s). Urologists can hardly hold themselves back and are out with all sorts of treatments. Sometimes, while a life may be saved, a life may be taken. I have experienced for the second time in my life, the issue. It does happen, but no one emphasizes that point.

    The first time I posted this information on was in October 2011. Yes. That was 7 months ago. And it is what Gary Schwitzer at HealthNewsReview has brought up in his blog “Outrageous…an earthquake…an enormous game changer” – but it was there for all to see for 7 months!

    News coverage of the Task Force’s new recommendation against prostate cancer screening was often hyperbolic and sensational, ignoring the fact that the published recommendation first appeared in draft form in October, fully 7 months ago, and that it was available for public comment for two time periods late last fall.

    The news coverage was not surprising, was not unexpected, and the rationale and supporting evidence was posted online for anyone to comment on for 7 full months. Where was all the news coverage of that opportunity for the past seven months?

    This reminds me of the anemia drug issue. The FDA first warned about prescribing drugs for anemia in cancer patients in early 2007. It wasn’t until 4 years later, the issue seemed to be finally resolved: using pharmaceutical EPO in cancer is harmful, like in increasing mortality in cancer patients.

    And it wasn’t until this year that it was exposed that dozens of doctors influenced their colleagues to use pharmaceutical EPO for unapproved indications such as cancer-related fatigue (anemia). There have been several nuclear explosions in clinical oncology. Interestingly, it is the highest levels of academia who are most tainted.

    But as in the anemia drug issue, the PSA screening issue will probably play out as one more cudgel to beat the more reasonable and gentle practitioners, who either largely avoided such abuse or were led down the path by the path by the scholars, who will themselves skip out unfazed.

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