PSA and the media
November 29, 2007 8:45 AM   Subscribe

“If you’re a prostate cancer survivor, one of the hardest things to question is whether your treatment was worth it.”
In 2003 Professor Alan Coates, then chief executive of the Cancer Council of Australia, caused a media storm, when he suggested that based on available evidence he personally would not undergo PSA screening for prostate cancer. This month's RSM journal analyses the Australian media response in detail.
posted by roofus (43 comments total) 2 users marked this as a favorite

 
This is an interesting controversy that really should not be at all.

Generally, if you are in reasonable health and expect, barring an accident or cancer, to live out a full life because you exercised modest effort not to kill yourself from alcohol, tobacco, or obesity related illness, ignoring a PSA test is simply stupid.

Screening decisions operate on a paradigm of a sudden requirement to screen mass numbers of people. Your average 50 year old male does not awaken with an urge to get a finger stuck up his ass and get blood drawn. But your non-average male, who has deliberately chosen to stay as healthy as possible, is the one that needs it. I've watched half a dozen men die of prostate cancer in their sixties as it hit them in their brain and bones and have yet, in fifteen years, to see a complication from screening.

Men will choose any reason imaginable to avoid the doctor, and campaigns/comments like those from Coates are a major disservice. If anyone on the planet had the temerity to suggest that mammograms were pointless they would have their ass handed to them.

And quibbling over the dollars spent on prostate screening for healthy men when we are incinerating mountains of cash on the treatment of smoking and obesity related illness is truly shameful.
posted by docpops at 8:54 AM on November 29, 2007 [3 favorites]


I don't think he was worried so much about complications from screening, as complications from unwarranted prostatectomy for slow moving non-lethal tumours.
posted by roofus at 8:59 AM on November 29, 2007 [1 favorite]


slow moving non-lethal tumours

Which was exactly why my patients died. I have yet to meet a male under 80 that wasn't fighting a severe chronic illness that felt like waking every day wondering if an errant malignant prostate cell had broken free into his pelvis was a nice way to live out his life.

Prostatectomy is certainly no more devastating, in an era of nerve-sparing surgery, than mastectomy was and still is for women. (Disclaimer: I have had neither).
posted by docpops at 9:03 AM on November 29, 2007


If anyone on the planet had the temerity to suggest that mammograms were pointless they would have their ass handed to them.

Actually, NPR had a story recently that, IIRC, suggested almost exactly that. The listen link doesn't see to work on my computer, but I seem to recall them saying that certain classes of women (under 40 for anyone, under 50 for those with no family history?) shouldn't bother getting tested.
posted by DU at 9:05 AM on November 29, 2007


Professor Michael Baum who was one of my medical school profs, is indeed a "vocal critic" of breast cancer screening.
posted by roofus at 9:09 AM on November 29, 2007 [1 favorite]


I don't really understand. Is the Euro/Australian medical community basically arguing that "since the PSA test [the blood drawing] is not always acccurate, causing some men to undergo needless treatment for prostate cancer, therefore everyone should stop getting tested"?

Also, Coates' statement does seem particularly inflammatory to me. "I won't take the test because it might find things that didn't need to be found, or it might find things when it's too late to fix them"? That sounds really very much like sticking one's fingers in one ears and talking over the person saying the unpleasant things, "Neener neener, I can't hear you so what you're saying must not exist."

But, IANAD. It's certainly easy for me to see how the Australian media has freaked over Coates' statement, and it's easy for me to see why he'd be low-hanging fruit -- "the crazy outlier doctor" -- but maybe not being medically trained keeps me from understanding that the Australian medical community is in fact being reasonable here.

I hope our medical MeFites weigh in. I think the various controversies around preventive screening are worth talking about, because it's an area where we (at least Americans) can be easy prey for seemingly altruistic messages that are secretly a shill for whatever pharma campaign has the big bucks this month (see also: HPV screening).
posted by pineapple at 9:15 AM on November 29, 2007


Eh? My father in law was screened, prostate cancer found, treated (something I wouldn't do for kicks - it involves something a bit like a robot sewing machine going up your butt and sewing threads beaded with radioactive isotopes through your prostate. Yes, you get a general for that) and is now doing fairly well. He's a bit annoyed that he can't sit his granddaughter on his lap for a bit, but he's not dying horribly from cancer which is pretty much the alternative.

Suggesting that he shouldn't have been screened is hugely irresponsible and stupid.
posted by Artw at 9:27 AM on November 29, 2007


Well, the paradigm I use to reconcile screening is sort of like this:

Guidelines on cancer screening are based on a lot of factors, such as cost per live saved, potential morbidity (i.e. stuff that sucks but doesn't kill like infections after biopsy, etc.), and whather the screening test is even remotely sensitive or specific.

But on an individual basis a lot of that simply becomes less relevant. You have a man or woman in your office that takes great care of themselves. Maybe they have three kids in school and their parents lived into their nineties. You have a whole day ahead of you where you'll burn through two Rx pads refilling drugs for diabetics, hypertensives, and heart patients who smoked and ate themselves into health disasters. So that guy/gal in your examining room that chews up a minute fraction of time and money from the health care system because of their own efforts? You really have the stones to tell them they shouldn't get a PSA or that a sigmoidoscopy that looks at a third of their colon but not the rest but is cheaper and perhaps wiser from a cost perspective than a full colonoscopy is in their best interest?

Bullshit.
posted by docpops at 9:27 AM on November 29, 2007 [1 favorite]


..."since the PSA test [the blood drawing] is not always acccurate, causing some men to undergo needless treatment for prostate cancer, therefore everyone should stop getting tested"?

Just to help me (and presumably others) understand this: Between a positive PSA test and a prostatectomy, there'd be a confirmatory biopsy taken and analyzed, no?
posted by pax digita at 9:29 AM on November 29, 2007


docpops, you make a number of very true points, but I think you miss the message of the article.

The question is if, on average, you would have a better quality of life with or without screening. While the screening itself doesn't result in adverse health outcomes, it does tend to lead to treatment of found cancers. These treatments come with significant risk of impotence and incontinence.

Prostate cancer has a certain probability, undetected and untreated, of causing death or reducing quality of life. Research suggests that, undetected and untreated, prostrate cancer, statistically speaking, will not be your cause of death (you'll die of something else first) or reduce your quality of life (you die of something else without ever knowing you had prostrate cancer). Thus screening and treatment, with the risk of impotence and/or incontinence is, statistically speaking, a bad bet.

That said, my dad was screened and treated without adverse effects. Theres always anecdotal counter-examples.

There's a second issue. Given a limited number of healthcare dollars, one has to ask where you get the most bang (improved healthcare outcomes) for your buck. The article suggests that the screening and treatment of prostrate cancer, applied to a population, may on average adversely impact quality of life. There of lots of healthcare expenditures that have clear positive effects.

You make a good point that certain subsets of the population may be more likely to die or be adversely effected by prostrate cancer, as their lifestyle choices allow them to avoid other sources of morbidity. Simply put, the longer you live the better the chance your undetected and untreated prostrate cancer will kill you. I don't know if there is research on average healthcare outcomes for screening and treatment of healthy-lifestyle population subsets.
posted by sisquoc15 at 9:29 AM on November 29, 2007


By the way, my dad received HIFU treatment in Germany, as it wasn't available in the states at the time.
posted by sisquoc15 at 9:34 AM on November 29, 2007 [1 favorite]


The people who really need screening are the ones least likely to have access to it -- the uninsured.

If anyone on the planet had the temerity to suggest that mammograms were pointless they would have their ass handed to them.

Plenty of patient advocates are unhappy with mammograms as a screening mechanism. Including the women undergoing a painful and incredibly inaccurate test.

Meanwhile, the change in recommendation a few years back that pap smears need only be performed every 2-3 years for women over 30 with no recent history of abnormal test results means that women will forgo what is frequently the only checkup they get. Have insurance companies started to reduce coverage of "unnecessary" pap smears yet? They most certainly will, given that the change in recommendations is endorsed by the ACS.
posted by desuetude at 9:38 AM on November 29, 2007


Just to help me (and presumably others) understand this: Between a positive PSA test and a prostatectomy, there'd be a confirmatory biopsy taken and analyzed, no?

Yes.

I spend a good deal of my time looking at them btw. Typically for just for elevated PSA you will have 6 needle core biopsies taken (usually ultrasound guided - needle-gun up the butt). For people who are being followed for intraepithelial neoplasia (precursor-lesion and often found in biopsies with carcinoma) they will have repeat biopsies with more sampling that just the sextant biopsies. Primarily to decrease the amount of sampling error that might have caused us to see your PIN but not your carcinoma.
posted by i_am_a_Jedi at 9:42 AM on November 29, 2007


sisquoc15 gets it exactly right. I think a big part of the problem--and this goes far beyond just screenings for prostate cancer into all sorts of screenings that are now recommended--is that all the anecdotal stories we have are by their very nature only on one side of the argument. You only hear about the guy who got screened and caught the cancer early, or didn't get screened and died of cancer. (Both of which seem to argue for more aggressive screening campaigns.) You don't hear about the guy who wasn't screened, and as a result didn't go through unnecessary surgery (perhaps with further complications or death) when he didn't actually have cancer. So I think there's perhaps an understandable impulse for doctors to be very pro-screening, because *all the cases they've personally witnessed* have shown it was useful or would have been useful. Since you never see the people who did not have a screening and that was the right choice (in terms of avoiding unnecessary surgery), it's hard to get a sense of which population is bigger (or that the second population exists at all). And among people who do get screened, get a false positive but later end up to not actually have cancer--I think the impulse is to view that as a "near miss" or lucky break, rather than the negative outcome inherent in aggressively expanding screenings to ever-larger populations.

Slate did a story on lung cancer screening that I think makes exactly the same point: there's a definite medical cost to screenings in terms of false-positives. There was another story on NPR that made the same point about the rise in false positives as a result of the expansion of screenings for skin cancer; that one focuses not so much on the risk of death from biopsies, but I think it does a nice job of pointing out the real psychological impact that a false positive can have. It's not "no big deal" or a "lucky break" to be told that you have cancer then have it not be true--that's a negative outcome, and we should weigh the costs of the negative outcomes of expanded screenings against the benefits they provide.
posted by iminurmefi at 9:45 AM on November 29, 2007


The whole point of PSA screening (as opposed to Digital Rectal Exam) is to pick up prostate cancer when it is smaller, lower stage and easier to resect. So finding tumours earlier = better.

However, autopsy studies show that a good percentage of men have indolent prostate cancer at the time of death, that *does not contribute to the death* and presumably did not affect quality of life. PSA would pick up these tumours too.

So the whole controversy of PSA screening is picking up aggressive prostate cancer earlier, versus unnecessary treatment.

Unfortunately, the pro-screening people are ignoring this controversy and pushing for new lower cutoffs for PSA screening. The old cutoff for biopsy is 10 ng/mL, while some researchers are pushing for a 4ng/mL limit. This would result in more biopsies, and more prostatectomies, each with accompanying mortality/morbidity. This hardline approach is going to piss off a lot of the more conservative crowd.
posted by desiderandus at 9:50 AM on November 29, 2007


I am underwhelmed by the data supporting mammograms. But I generally keep my mouth shut because people tend to freak out if you say anything negative about mammograms. I think it would be difficult to be a medical leader trying to get a real discussion going about these screening issues.
posted by ClaudiaCenter at 9:53 AM on November 29, 2007


sisquoc - thanks for your rebuttals. Again, it is the attempt to best mesh mass screening paradigms with individual cases that creates the dilemma. Since I operate in the individual arena, I tend to use the screening guidelines as templates for decision making but never as absolutes. These screening decisions are made up of random populations of persons and not necessarily the healthiest among us.

As for screening the uninsured, they typically have far greater immediate problems than PSA testing.
posted by docpops at 9:53 AM on November 29, 2007


One of the bits that really caught my attention from the NPR story recently about the unintended side effect of so many screenings was that, upon autopsy, pretty much all of the guys over 60 had a prostate cancer. It might be little, it might be big, but they just about all had one. Now, there was no cite on the air, but it did make me reconsider the pros and cons of screening for that, given what the standard treatments can be/cost/etc.
posted by adipocere at 9:55 AM on November 29, 2007


Of course, this whole controversy is just that until someone does a study that uses primary endpoints like mortality or QALYs to show if PSA screening is beneficial :)
posted by desiderandus at 10:00 AM on November 29, 2007


desuetude--I think PAP smears are another interesting example of a place where there may be too much screening going on. According to the U.S. Preventive Services Task Force, there's no direct evidence that annual screening achieves better outcomes than screening every 3 years. Additionally, the majority of cervical cancers in the United States occur in women who have never been screened or who have not been screened within the past 5 years. (citation) Since PAP smears are not terrible precise tests, there's a whole lot of false positives for every true positive. There was a recent askme about weighing the costs associated with treating an abnormal PAP (note, treatment of lesions can cause infertility, which would be pretty devastating for a lot of women and probably should be avoided unless we're really really sure they have cancer).

And I'm not sure it's a bad thing that women wouldn't go into the doctor for a "check up" every year if they weren't covered for a PAP. I'm not aware of any evidence that a yearly check up does any medical good on a population level. (In fact, there's been recent skepticism that yearly physicals for adults are a good use of our obviously limited health care dollars.)
posted by iminurmefi at 10:09 AM on November 29, 2007 [1 favorite]


note, treatment of lesions can cause infertility, which would be pretty devastating for a lot of women and probably should be avoided unless we're really really sure they have cancer).

Please clarify that comment. Treatment of cervical dysplasia does not cause infertility.

In fact, there's been recent skepticism that yearly physicals for adults are a good use of our obviously limited health care dollars.)

Somewhat true, and sadder still that we are counseling healthy people to stop pestering us for periodic check-ups so we can piss away billions on treating lifestyle inflicted diseases.
posted by docpops at 10:15 AM on November 29, 2007


I think we probably are more than due as a society for an intensive debate about whether intensive medicine is operating and being used in a socially and individually appropriate fashion.

We need to have this debate not only because of the monetary cost of many treatments (as with most cancer treatments), but far more importantly because the cost to quality of life from many procedures may be worse than living with (and possibly dying from) the disease.

Medical practice, with its dedication to "extending life" has built a power structure in which extending the quantitative outcomes is often more important than the qualitative ones. In the case of prostate oncology, the goal has been to identify more people who are in the early stages of developing prostate cancer and treat them. The critical argument is that in doing so, oncology may be worsening the lives of many more people than are ever going to actually, qualitatively suffer or die from the cancer. There is apparently a significant difference between prostate cancer as is being diagnosed by medical technology, and "real, existing" prostate cancer -- that which actually will come to disable or kill people. In this sector of medicine, "extending life" appears to be wholly dominant over "reducing suffering."

Now, this is the philosophical problem with modern, technological medicine. But it's linked to something else, which is why I'm calling it a power structure. Institutionally, something like promoting prostate screening, and thus ultimately ramping up the number of people receiving treatment for early stage prostate cancer, has a particular wealth / prestige / professional power effect for those professionals involved in it. They gain a greater share of resources, they gain power over a greater number of people, they gain additional prestige within the hierarchy of their field and within broader society. They're facilitated in doing this by the dominant medical philosophy of "extend life", and they may even wholly buy into that and may not be conscious of the power effects of their success and what "extend life" means to their career and their position in society, but the power they get is what allows them to further this regime, and what undergirds the backlash in cases like Coates' statement.

In the case of prostate treatment, urinary incontinence and impotence are reasonably serious but not completely devastating side effects of treatment. There are a lot of medical treatments (in oncology and other disciplines) that do far, far worse to people in the name of life extension. But one of the things that happens is that as an institutional regime gains power, as one might argue the screening regime has, you get scope creep, you get an increase in the number of domains that it is applied to (which of course enhances its power still further). Other, more devastating courses of treatment become professionally acceptable if they further the goal, which for screening oncology is the early identification and treatment of potentially lethal disease, and for oncology in general and most of medicine is maximizing life duration.

So yeah, I've just come off a week of intense academic writing, so I'm completely failing to conclude this post in an effective way (hmmm, that sounds exactly like my last paper actually), but yes, as a civilization we need to have a debate about this and I think what we'll find is that a lot of what is presently seen as essential medicine is on a net level both personally and socially harmful. And many professionals will fight this debate tooth and nail, as was seen in the Coates controversy, both because they have bought into a particular ideology of medicine and because they are materially and socially invested in their institution's dominance.
posted by kowalski at 10:19 AM on November 29, 2007 [4 favorites]


As for screening the uninsured, they typically have far greater immediate problems than PSA testing.

Uh, yes, like the lack of basic health care. This is exactly my point -- not that massive "screen the uninsured" campaigns will prevent cancer, but that those of us with insurance are receiving medical attention, including the relative luxury of various preventative cancer screenings. Those without insurance just go to the emergency room if the situation is dire enough, but lack the opportunity to discuss their overall health with a physician.
posted by desuetude at 10:23 AM on November 29, 2007


From the first link:

“It was tough treatment in those days … Platinum’s a drug that makes you vomit terribly. There weren’t good vomiting drugs in the hospital but we used to send them [the patients] down to State Street to pick up a joint,” he says with a chuckle.

Ah, Madison.
posted by thanotopsis at 10:35 AM on November 29, 2007


My granddad died of prostate cancer. It was diagnosed and treated early. He spent the last few years of his life wearing a diaper and generally uncomfortable and embarrassed. He regretted getting treatment.

I think I have to agree with him: I'd rather die relatively quickly. And since it runs in the family, my chances that I will have to make that decision are greater than most.
posted by ten pounds of inedita at 10:41 AM on November 29, 2007 [1 favorite]


kowalski, it isn't as bad as you say. Doctors have to get medical treatment too, so as in this case with Coates, limits get drawn by insiders themselves.
posted by desiderandus at 10:43 AM on November 29, 2007


Uh, yes, like the lack of basic health care.

Try not to be obtuse, since we are essentially saying the same thing.

And Kowalski, you must be an academic, because you don't seem to have the slightest insight about the motivations of the overwhelming majority of physicians. I guess the physician rebuttal might be along the lines of academics and statisticians manufacturing artificial slippery slope arguments to ensure a steady stream of grant monies to keep the flow of dissertations going strong.

Screening for diseases that have yet to take hold of a person and cause morbidity and mortality is exactly what we do not do enough of in America. The fact that our methods for screening for cancers and the subsequent treatment thereof are not perfect is hardly a reason to choose not to do so, but rather it should spur us to strive for greater effciencys and testing accuracy. These people seem to feel it's responsible to tear down screening simply because the current state of the art is not yet perfect. But nothing ever is.
posted by docpops at 10:48 AM on November 29, 2007


...ensure a steady stream of grant monies to keep the flow of dissertations [or other relevant goods] going strong.
You don't think this doesn't happen?
posted by kowalski at 10:59 AM on November 29, 2007


*apologies for the double negative!*
posted by kowalski at 11:00 AM on November 29, 2007


Docpops, your position seems to be this (not meaning to caricature here, just trying to be brief):

--The surgery is better now, so the incontinence/impotence issues should not be weighed so heavily;

--Healthy people who take care of themselves and have a good family history (parents who lived into their nineties) are more likely to die of the disease and are better candidates for screening.

--The number of people who weren’t screened and therefore didn’t go through unnecessary surgery or experience the serious complications or side effects like incontinence/impotence doesn’t figure into your decision making. (sisquoc15 and iminurmefi’s point)

--The cost shouldn’t matter because we blow much more money treating people whose diseases are self-inflicted.

But

--the risk of onerous side-effects is still very high, is it not?

--healthy people who take care of themselves and have parents who lived into their nineties sound like they would be less likely to develop the disease and more likely to die of being old, which would weigh in favor of not having the test;

--sisquoc15 and iminurmefi’s points about unscreened people who had the disease but avoided unnecessary onerous treatment seems highly relevant but doesn't appear to enter into your thinking;

--why should the costs of lifestyle-related illness have any bearing on whether PSA screening is rational or not? That’s an emotional response not an evidence-based one.

so?
posted by cogneuro at 12:54 PM on November 29, 2007 [1 favorite]


Another primary care doctor, here, who is much less enthusiastic about prostate cancer screening but I definitely see where docpops is coming from. Given the chances we take with our lives all the time, refusal of a PSA and a finger up the butt isn't going to get me outraged. I usually present both sides of the argument in the few minutes I can spend on this with a patient and if the patient doesn't immediately know what to do, I ask them "Do you want to think about it and get more information or do you want to know what I personally would do?" Boom. Move on to the next problem.

Usually, in these discussions on MeFi there's not a lot of tolerance for the more conservative options. With this issue, there are reasonable arguments on both sides. We are not talking about whether you should have your cholesterol checked or whether you should stop smoking. In this case, the harms are probably (for an otherwise healthy person) slightly outweighed by the benefits. Of course I'd recommend it. Do I think it's crazy if you want to spend your precious 15 minutes in my office talking to me about erectile dysfunction instead of prostate cancer screening? Hell no.
posted by Slarty Bartfast at 1:39 PM on November 29, 2007 [1 favorite]


cogneuro, I favorited your response for it's succinct eloquence. The only point I feel compelled to respond to is perhaps the one regarding evidenced based vs. emotional based.

That's very valid. But it's also worth pointing out that in my brief career and training, numerous evidenced based practices were recently seen as unproven and therefore not appropriate even though all empiric evidence suggested otherwise, and thus had we adhered to what was proven vs. what seemed intuitively obvious would have resulted in adverse consequences. A good example is colon cancer screening. Full colonsocopy is now the norm for a healthy person of average or higher risk, but while it was being debated in the last ten years three persons that I know of in my and another practice died in their prime of right sided colon cancer because their GI docs wouldn't/couldn't offer them a better test (and much more well tolerated) that would have detected their cancer. So if you are in primary care and might care for a patient for several decades, you often find yourself thinking in terms that are not simply figures on a power-point slide outlining cost/benefit analysis, but rather what might actually be in a particular patient's best interest based on empiric as well as actual longitudinal controlled-study evidence.

Quite frankly this (prostate) issue is debated so extensively that the more aggressive screening camp is starting to get more and more credibility. I would also point out that more information is not a bad thing. If someone chooses to forego treatment for prostate cancer that's their decision, but to not even check for it, in my opinion, is malpractice.
posted by docpops at 1:57 PM on November 29, 2007


well, I'm an academic.

(now I'm going to get prostate cancer for sure...!)
posted by cogneuro at 2:02 PM on November 29, 2007


Thanks for the thoughtful discussion docpops and cogneuro.

A big part of the disconnect here is that the answer to this question depends on who's asking it.

As a doctor, will I do more harm than good if I recommend screening this particular patient?

As a policymaker, will I do more harm than good if I recommend that men in general should be screened?

Those are very different questions with different answers determined by different kinds of reasoning and evidence.
posted by straight at 2:57 PM on November 29, 2007


Absolutely no evidence exists that PSA screening for prostate cancer is effective at reducing mortality or morbidity. In fact, it probably increases morbidity, so the question is whether any mortality benefit exists. There are currently two large-scale randomized trials underway (PLCO in the US and ERSPC in Europe) to see if such screening can reduce mortality from prostate cancer. Until then, it probably is a good idea not to get routine testing for PSA.

That said, if you have symptoms and your doctor orders a PSA, then, by all means, follow up on it if it is positive.
posted by Mental Wimp at 3:43 PM on November 29, 2007


Links: PLCO and ERSPC.
posted by Mental Wimp at 3:58 PM on November 29, 2007


#@!&*($)%

PLCO
posted by Mental Wimp at 3:58 PM on November 29, 2007


And Kowalski, you must be an academic, because you don't seem to have the slightest insight about the motivations of the overwhelming majority of physicians.

This is undeservedly patronising. All doctors should be trying to be doing the best for their patients, and that means relying on best evidence, not anecdote.

If someone chooses to forego treatment for prostate cancer that's their decision, but to not even check for it, in my opinion, is malpractice.

Obviously we aren't screening all adult males, only those in a certain age bracket. There is however no Level 1 evidence to support any unselective target age range for screening. If I was recommended to undergo PSA screening by my primary care physician or urologist, against all current evidence based guidelines, and I consequently suffered a treatment related adverse event, I would consider that malpractice. All patients deserve proper information before consenting to screening, but media bias (and biased physicians) make it difficult for patients to understand the issues involved
posted by roofus at 4:10 PM on November 29, 2007 [1 favorite]


I just want to thank the participants in this thread. This has, for the very large part, been thoughtful and respectful.

I'm in healthcare, but on the executive/administration side. I think it is easy to rally behind "get screened!" movements, because you are making a good-faith effort to offer potentially life-saving services to your community. I've done it several times. Our offices have distributed pink ribbons and yellow wristbands and all of that. Pamphlets asking "have you been checked?" and similar.

But, I think that very often, quality of life considerations get brushed over if not totally ignored.

There's this notion, that's been touched on above, that the goal should always be focused on treating, removing, or eliminating disease... when the focus should truly always be on the welfare of the patient. And sometimes, as hard as it seems to believe, and as counter-intuitive as it may appear, the patient is best served by not attempting to "cure" them.
posted by Ynoxas at 8:30 PM on November 29, 2007 [1 favorite]


I think a big part of the problem...is that all the anecdotal stories we have are by their very nature only on one side of the argument. You only hear about the guy who got screened and caught the cancer early, or didn't get screened and died of cancer....You don't hear about the guy who wasn't screened, and as a result didn't go through unnecessary surgery...

The anecdotes I hear: two acquaintances of mine, both in their early 50s, an age not all that far away for me. Both appear to be in tip-top shape, especially for their age.

One is dealing with doctors recommending that he get aggressive prostate treatment.

The other had "nerve-sparing" surgery within the last couple of years, except that it didn't spare the nerve. He's resorted to vacuum pumps and such apparatus to try and bring back what he once had.

In both cases, I'm seeing aggressive intervention in the lives of men who are otherwise, to outwards appearances, normal. Neither is in any way old or sickly.

Anyway, in the middle-age-guy stories I hear first hand, that's how the drama is playing out.

All anecdotal, of course.
posted by gimonca at 9:06 PM on November 29, 2007 [1 favorite]


gimonca, understand as well [and maybe you already do] that prostate cancers differ tremendously in their aggressiveness and receptivity to treatment. The thing that is so perplexing about not screening is you are essentially saying that patients and doctors can't make informed treatment decisions. If your PSA jumps 80% in a year when you're in your 50's and it turns out to have a high Gleason score, you now have information you can use to determine a course of action.

The earlier poster who stated it would be considered malpractice if they were recommended to have a PSA test and eventually had a work-up related complication would be wise to pass that on to his physician. The list of all possible treatments that actually have evidenced-based proof behind them is vanishingly small, from pain management to antibiotics for numerous infectious clinical situations and management of an evolving myocardial infarction.
posted by docpops at 7:16 AM on November 30, 2007


docpops, I *would* argue that patients and doctors (for varying reasons) can't make truly informed, unbiased treatment decisions once the cat is out of the bag with respect to screenings.

On the patient side, I think it's a clear situation where the information asymmetry means that the patient will almost certainly do what a doctor advises. An average patient has nowhere near enough knowledge about this stuff--absent being a epidemiologist or health services researcher--and getting hit with a possible cancer diagnosis is the worst time to expect that someone will be able to go out and diligently research the facts until they know enough to make an informed decision. In reality, 99% of the time the patient will look to the doctor for guidance, as the doctor is the expert.

However, the problem is that doctors are going to be predisposed to "aggressive" treatment, for two reasons:

1. Liability--if the doctor says, "Well, your tests show some cause for concern, but I think we should just hang tight and see what happens," that might be the right course of action 90% of the time. However, that 10% when it's not, the patient may sue (or at least, I think many doctors would rightfully perceive that there's a risk of being sued for malpractice). On the other side, it will never happen that a patient sues for undergoing a biopsy or course of treatment that may reduce the quality of life, even if it wasn't necessary (because the patient and doctor will never know that it wasn't necessary, although based on the statistics there are undoubtedly cases where the person would have been fine without treatment). So the financial and legal considerations (and possibly ethical considerations, depending on how an individual doctor perceives the ethical standards of medicine) line up on the side of recommending treatment or further investigation every time there's anything other than the normal results on a screening.

2. I'd argue (and you may well disagree) that doctors are likely to have a cognitive bias towards assuming that treating is always preferable to not treating. For illustration, if we assume that 50% of men who would test positive for prostate cancer would be fine with no treatment and 50% will die with no treatment, it's very possible that the average urologist or oncologist is unable to accurately judge the size of each group. After all, that 50% of men who would be fine under this scenario with no treatment are either not going to be tested--in which case the doctor never sees them--or will test positive and be treated, but the doctor may well assume that the outcome of the disease absent treatment would be death, since he or she has no experience telling them otherwise. Since the people that the doctor actually sees day in and day out are people who did undergo screening, and who are either going to die (attributed to the cancer) or will survive (likely attributed to the treatment, whether that's the case or not), and it seems likely that the average doctor would conclude that it's always better to treat.

Even if you don't accept that medical professionals are subject to the cognitive bias in #2, I think the legal and financial concerns from #1 would still push a doctor towards recommending treatment. If we have evidence that suggests that screening more often and catching more cases of cancer does not actually decrease the mortality rate of prostate cancer--which, based on what I've read recently in the Washington Post is the case based on comparisons of the British health system and the US health system--I think we (as a country) need to do a better job of rethinking the supposition that more screening is always better and that there are no downsides to it.
posted by iminurmefi at 10:34 AM on November 30, 2007 [1 favorite]


If your PSA jumps 80% in a year when you're in your 50's and it turns out to have a high Gleason score, you now have information you can use to determine a course of action.

The problem is that it is impossible to tell with any certainty whether a prostate cancer you find will ever lead to symptoms, much less death. And in order to diagnosis the potentially insignificant ones you have to do a biopsy, which doesn't hurt the physician at all and fattens his wallet a little. If it's positive, you have to decide on a course of treatment, none of which are benign, except for watchful waiting. That means relooking at PSA, in which case you still have the same problem. Meanwhile, many men who otherwise would be perfectly healthy are incontinent or impotent because they screened for prostate cancer. This is in the face of zero evidence that mortality can be avoided by screening. It seems to me unethical for physicians to recommend screening under these circumstances.

Now if someone can show me evidence to the contrary (and I don't mean some authoritative figure declaring that screening must be done, I mean scientific evidence not contaminated by lead-time or length bias with valid controls), I'll quickly change my stance. But I know for fact that such data don't exist, because I am involved in research to produce it.
posted by Mental Wimp at 12:12 PM on November 30, 2007


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