I once asked a urologist what he thought about universal screening for prostate cancer by framing the question in very personal terms. I asked him about letting a doctor's finger to approach him. His answer: "Keep the finger away from me."
This was in 1989. And nothing has changed.
The Post reports on the USPSTF revision to PSA screening recommendation, downgrading prior enthusiasm. Note the recommendation is not to deny screening. It merely states insufficient evidedence at this time to support screening. The major difference from prior recommendations (as far as can tell at this point) is the withdrawal of a half-hearted OK that had been given to people at high risk, like African-Americans, people with a family history and especially, men over 75.
The level of protest is remarkable in its lack of scientific integrity. "Too bad, we're saving lives." Well, that's not what the data shows. Men are living longer since PSA screning has become widespread is the same as the autism argument. Maybe men are living longer because of MMR. Have you ever noticed how males get autism more often?
At the risk of offending my favorite urologist, PSA'a are remarkable at their ability to efficiently generate billable procedures (i.e. trans-rectal ultrasound guided biopsy). Those with the greatest interest in a recommendation for universal PSA screening own surgical facilities or benefit from the procedures generated.
The USPSTF is a government agency and since the government, as the country's largest payor, may be construed as having an interest in decreasing its expenses, this agency is not beyond a natural incentive to skew its conclusions. But if you think it through, it means that the standard of proof is necessarily higher. This kind of bias is one I can buy into as more trustworthy. Personal opinion.
The bottom line is that the more people I do PSA's on, I will probably save a life or two, but at the cost of several people going through unnecessary stress, procedures and complications. The sad part about prostate cancer is that the PSA will also detect a number of cancers for which treatment will fail, or be irrelevant due to intercurrent illnesses. By not doing PSA's, I can keep several people peacefully in the dark, but miss one or two cancers that could be impacted. Those people whose cancers are missed but for whom treatment will have no impact also represent a huge malpractice risk. These people are the ones most likely to sue for missed diagnosis, even though the truth may well suggest a different conclusion.
The USPSTF did the right thing, but it would be interesting to revisit their original endorsement of high-risk screening and what changed in the data to support a change in recommendation.
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6 comments:
I don't entirely disagree with your views on PSA screening, though they are a bit pessimistic. PSA screening must be DISCUSSED with patients as part of a proper informed consent process. Whether or not to proceed with screening, not to mention any followup from the screening results is very much patient driven.
For the record, while PSA screening may drive procedures, cystoscopy is not one of them. You may with to change you example to a TRUS Biopsy.
See "JAMA. 2004 Jan 7;291(1):15-6". It's about a case where, after long discussion with his doctor, patient elected to not get PSA done. Later got prostate cancer in his 50s, won millions. Guidelines aside, the "standard of care" is what presides in the courtroom. If everyone else in town is doing PSAs, that means you better do so as well.
IU: I stand corrected, cystoscopy is at best incidental to the symptoms that a may cause a patient to present and not directly related to an elevated PSA.
Paul: I have met Dan Merenstein and he is one of the smartest docs I know. You have stated the problem well, but certainly not the solution. You are suggesting that a community standard trumps the best scientific information available.
If we cannot define the basis of what we do and come to terms with the scientific basis of medical practice, the profession is in more trouble than an upside-down legal system would make it look.
That lawsuit described in JAMA is an outlier.
It's widely discussed in the law because it was such an unusual decision by a state court.
But it has not set a precedent. If a doctor discusses the pros and cons of PSA testing with a patient, the patient decides not to do it and develops fatal prostate cancer, it's extremely unlikely that the doctor would lose a suit.
In fact, in the state of Washington, if the doctors takes the patient through a process called "shared decision making" (now used at Dartmouth, Allegheny Hospital and a number of other places) state law now makes it very difficult to sue the doctor for malpractice.
Well, it is unfortunate that even if some men get a PSA, it may be too late for treatment, but this doesn't mean that we should stop the fight to get as many men possible tested for prostate cancer. Those only two extra lives you mentioned are extremely worth the effort, especially if you take into account their families.
I agree with Enlarged Prostate. There still needs to be wide-spread support for prostate testing. Thus, more education is spread. There are also natural ways to treat prostate cancer such as herbal supplements. Men should never give up and every man should be given the opportunity to fight their cancer, not live in the dark!
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