Panel advises against prostate cancer screening

Steve Williams · Oct 7, 2011

Panel advises against prostate cancer screening

By LAURAN NEERGAARD, AP

WASHINGTON — No major medical group recommends routine PSA blood tests to check men for prostate cancer, and now a government panel is saying they do more harm than good and healthy men should no longer receive the tests as part of routine cancer screening.

The panel's guidelines had long advised men over 75 to forgo the tests and the new recommendation extends that do-not-screen advice to healthy men of all ages.

The recommendation by the U.S. Preventive Services Task Force, being made public on Friday, will not come as a surprise to cancer specialists.

Yet, most men over 50 have had at least one PSA blood test, the assumption being that finding cancer early is always a good thing.

Not so, said Dr. Virginia Moyer of the Baylor College of Medicine, who heads the task force.

"We have put a huge amount of time, effort and energy into PSA screening and that time, effort and energy, that passion, should be going into finding a better test instead of using a test that doesn't work," Moyer told The Associated Press late Thursday.

Too much PSA, or prostate-specific antigen, in the blood only sometimes signals prostate cancer is brewing. It also can mean a benign enlarged prostate or an infection. Worse, screening often detects small tumors that will prove too slow-growing to be deadly. And there's no sure way to tell in advance who needs aggressive therapy.

The task force analyzed all the previous research on this subject, including five major studies, to evaluate whether routine screening reduces deaths from prostate cancer. The conclusion: There's little if any mortality benefit.

But there is harm from routine screening: impotence, incontinence, infections, even death that can come from the biopsies, surgery and radiation, Moyer said.

One study estimated 2 of every 5 men whose prostate cancer was caught through a PSA test had tumors too slow-growing to ever be a threat.

Yet Moyer said 30 percent of men who are treated for PSA-discovered prostate cancer suffer significant side effects, sometimes death, from the resulting treatment.

About a third of men ages 40 to 60 have brewing prostate cancer but "the huge majority of them will never know it in their lifetime if they are not screened," she added.

The task force previously had considered the evidence for or against PSA screening inconclusive. The new recommendation says not to routinely screen. That recommendation is a draft that is open for public comment beginning next week.

"We have been long concerned, and it has been apparent for some years, that some supporters of prostate cancer screening have overstated, exaggerated and in some cases misled men about the evidence supporting its effectiveness," said Dr. Otis Brawley of the American Cancer Society in a statement. "We need balanced, truthful information to be made widely available to physicians and patients when making important health decisions."

The society had not seen the new recommendation yet, but has long advised men to consider the pros and cons of PSA screening before deciding on their own.

Moyer said the recommendation only means that doctors shouldn't bring up the option for healthy men. If a man asks for a PSA test and wants it after being informed of the evidence, he should receive it, she said. Likewise, it's appropriate to use PSA tests to examine a man with possible prostate symptoms.

MylesBAstor · Oct 7, 2011

Steve Williams said:
Panel advises against prostate cancer screening

By LAURAN NEERGAARD, AP

WASHINGTON — No major medical group recommends routine PSA blood tests to check men for prostate cancer, and now a government panel is saying they do more harm than good and healthy men should no longer receive the tests as part of routine cancer screening.

The panel's guidelines had long advised men over 75 to forgo the tests and the new recommendation extends that do-not-screen advice to healthy men of all ages.

The recommendation by the U.S. Preventive Services Task Force, being made public on Friday, will not come as a surprise to cancer specialists.

Yet, most men over 50 have had at least one PSA blood test, the assumption being that finding cancer early is always a good thing.

Not so, said Dr. Virginia Moyer of the Baylor College of Medicine, who heads the task force.

"We have put a huge amount of time, effort and energy into PSA screening and that time, effort and energy, that passion, should be going into finding a better test instead of using a test that doesn't work," Moyer told The Associated Press late Thursday.

Too much PSA, or prostate-specific antigen, in the blood only sometimes signals prostate cancer is brewing. It also can mean a benign enlarged prostate or an infection. Worse, screening often detects small tumors that will prove too slow-growing to be deadly. And there's no sure way to tell in advance who needs aggressive therapy.

The task force analyzed all the previous research on this subject, including five major studies, to evaluate whether routine screening reduces deaths from prostate cancer. The conclusion: There's little if any mortality benefit.

But there is harm from routine screening: impotence, incontinence, infections, even death that can come from the biopsies, surgery and radiation, Moyer said.

One study estimated 2 of every 5 men whose prostate cancer was caught through a PSA test had tumors too slow-growing to ever be a threat.

Yet Moyer said 30 percent of men who are treated for PSA-discovered prostate cancer suffer significant side effects, sometimes death, from the resulting treatment.

About a third of men ages 40 to 60 have brewing prostate cancer but "the huge majority of them will never know it in their lifetime if they are not screened," she added.

The task force previously had considered the evidence for or against PSA screening inconclusive. The new recommendation says not to routinely screen. That recommendation is a draft that is open for public comment beginning next week.

"We have been long concerned, and it has been apparent for some years, that some supporters of prostate cancer screening have overstated, exaggerated and in some cases misled men about the evidence supporting its effectiveness," said Dr. Otis Brawley of the American Cancer Society in a statement. "We need balanced, truthful information to be made widely available to physicians and patients when making important health decisions."

The society had not seen the new recommendation yet, but has long advised men to consider the pros and cons of PSA screening before deciding on their own.

Moyer said the recommendation only means that doctors shouldn't bring up the option for healthy men. If a man asks for a PSA test and wants it after being informed of the evidence, he should receive it, she said. Likewise, it's appropriate to use PSA tests to examine a man with possible prostate symptoms.

I am not shocked. My ex-wife many years ago did a project for her MPH where she did a cost cost/benefit analysis for the PAP smear. When she crunched the numbers, including number of tumors detected, false positives and overall costs, the PAP smear is not cost effective either.

OTOH, are you going to tell women that they can't have a PAP smear if you're the one where the PAP smear picks up the tumor? Same with men. In fact, many refer to prostate cancer as the breast cancer of men

In fact, we've already had a mistep in the interpretation of prostate cancer data; several years back, there was a study done in Sweden (I think) where they found that men tended to die of other things than the prostate cancer. So the insurance co's immediately jumped on this study to try and eliminate the PSA test until someone pointed out that the types/grades of prostate cancer seen in the US weren't the same as in Sweden. (Of course, the PSA test has always had its grey area.)

Aren't they having the same argument now for Avastin too

I think the bottom line is the bottom line

Costs are so skyrocketing for Rx that the insurance co's are looking for ways to cut their costs. That's not to say like the article states that there's definitely room for a better test. But until then....

audioguy · Oct 7, 2011

I have a very good friend who (I suspect) would strongly disagree with this report. Through a PSA test, they have discovered a tumor they defined as "Pretty aggressive. Gleason scale 6".

I don't know what that exactly means but they are going to discuss his options next week.

Phelonious Ponk · Oct 7, 2011

"We have put a huge amount of time, effort and energy into PSA screening and that time, effort and energy, that passion, should be going into finding a better test instead of using a test that doesn't work," Moyer told The Associated Press late Thursday.

Color me skeptical. Nothing in the rest of the article says the test doesn't work. It says it gives positives for cancers that will grow so slow that they will never be an issue. It says that the options one might choose after receiving a positive can have adverse effects (it implies there are adverse effects to the PSA test but a careful reading says thos effects are from the biopsy, not the test). It gives us reason to be conservative about what we do with the information gained from the PSA test but it doesn't really say the PSA itself is either ineffective or detrimental. In fact, it seems to say that the PSA discovers signs of prostate cancer so small, so early that it may actually be uncovering problems that will never become threatening in the patient's life time. That sounds pretty effective to me. What it also says, overtly, is that routine PSA screening is expensive. One more time...

"We have put a huge amount of time, effort and energy into PSA screening and that time, effort and energy, that passion, should be going into finding a better test instead of using a test that doesn't work," Moyer told The Associated Press late Thursday.

...so, time, effort and passion are great. Are the insurance companies that will save millions from disallowing routine PSA screenings going to put that money into developing a better test? No, I didn't think so...

Tim

audioguy · Oct 7, 2011

Phelonious Ponk said:
...so, time, effort and passion are great. Are the insurance companies that will save millions from disallowing routine PSA screenings going to put that money into developing a better test? No, I didn't think so...

Tim

It's called "managed care"...... The insurance companies "manage" to make money and you can "manage" on your own.

MylesBAstor · Oct 7, 2011

audioguy said:
It's called "managed care"...... The insurance companies "manage" to make money and you can "manage" on your own.

Managed care has become a joke! It really doesn't save money. Oh, sure it does for the first year, but then it's all over. My ex- saw that when she ran the first second opinion program in the country and called it the "sentinel effect."

Thing is, all these managed care, insurance co's do is put money in the pockets of their shareholders. If someone's going to make the money, sorry I want it going to my doc.

Steve Williams · Oct 7, 2011

Tim

I agree. I have my PSA done once a year. One of my profs used to say " statistics are for losers

Phelonious Ponk · Oct 7, 2011

MylesBAstor said:
Managed care has become a joke! It really doesn't save money. Oh, sure it does for the first year, but then it's all over. My ex- saw that when she ran the first second opinion program in the country and called it the "sentinel effect."

Thing is, all these managed care, insurance co's do is put money in the pockets of their shareholders. If someone's going to make the money, sorry I want it going to my doc.

It is the only outcome anyone could expect. The publicly-traded company's only objective is shareholder equity. That's its job, its purpose. Nothing in the world wrong with that when building widgets. We, as a nation, just need to decide if that should be the sole motivation behind our healthcare system.

Tim

microstrip · Oct 7, 2011

Steve Williams said:
(...) One of my profs used to say " statistics are for losers

Oops! Now I see why audiophiles never agree ...

Steve Williams · Oct 7, 2011

talking medicine here now metronimo not audio

jazdoc · Oct 7, 2011

Wow. This thread has taken an not completely unexpected turn which demonstrates why it is so difficult to 'reform' our healthcare system.

To start with, a screening test by definition tests on a large, asymptomatic population at increased risk for disease, i.e. prostate cancer in men and PAP smears in women. For a screening test to be worthwhile the disease prevelance in the screened, asymptomatic population must be high enough to make screening effective. Additionally, Bayes' theorem, mandates that the test must have very high specificity and specificity. Even fulfilling these conditions for typical rates of disease prevalence, a screening test typically has way more false positives than true positives. Breast cancer is the second most common cancer in females, yet false positives leading to biopsies outnumber true positives by 3-4:1.

But simply finding disease is not enough. It only adds expense (to the patient and society) not to mention worry to find an asymptomatic cancer which won't kill you unless you can identiy it as an indolent neoplasm. If you live long enough, you will get a thyroid or prostate cancer, yet the vast majority of these are clinically irrelevant.

Ultimately the effectiveness of a screening test is judged not by detecting disease but by improving quality and quantity of life as measured in population 'life-years'. For example, outcomes based analysis prove that PAP smears significantly reduce incidence of cervical carcinoma. Finding undiagnosed disease without impacting patient longevity is the definition of a useless screening test. That doesn't mean that in limited cases, an ineffective test might detect the disease at an early stage and positively impact an individual's outcome, only that this is not the case for the entire screened population.

In this case, researchers have analyzed the data and determined the PSA is not a useful tool for screening the population. Isn't advocating continuing to spend money on a ineffective screening test so that providers save money 'a false choice'? And isn't a chief rationale for those who advocate a single payer system the elimination of waste?

A single payer system can only decrease costs by rationing care by restricting access. In theory this is a reasonable idea. We ration our food intake, luxury car consumption and yes high end audio purchases based on our unique personal circumstances including taste and financial resources. If health care is a 'right' that should be provided by the state to its citizens, does that include the right for all the health care an individual desires? Right now, if someone wants to purchase a useless screening test they are able to do so (provided they can get a script).

Moreover, if the state is providing your health care doesn't it have a profound interest and the moral obligation to try and change behaviors that add to the health care costs of society? And if you persist in these unhealthy behaviors, doesn't the state have the right and the duty to restrict health expenditures resulting from these actions?

MylesBAstor · Oct 7, 2011

jazdoc said:
Wow. This thread has taken an not completely unexpected turn which demonstrates why it is so difficult to 'reform' our healthcare system.

To start with, a screening test by definition tests on a large, asymptomatic population at increased risk for disease, i.e. prostate cancer in men and PAP smears in women. For a screening test to be worthwhile the disease prevelance in the screened, asymptomatic population must be high enough to make screening effective. Additionally, Bayes' theorem, mandates that the test must have very high specificity and specificity. Even fulfilling these conditions for typical rates of disease prevalence, a screening test typically has way more false positives than true positives. Breast cancer is the second most common cancer in females, yet false positives leading to biopsies outnumber true positives by 3-4:1.

But simply finding disease is not enough. It only adds expense (to the patient and society) not to mention worry to find an asymptomatic cancer which won't kill you unless you can identiy it as an indolent neoplasm. If you live long enough, you will get a thyroid or prostate cancer, yet the vast majority of these are clinically irrelevant.

Ultimately the effectiveness of a screening test is judged not by detecting disease but by improving quality and quantity of life as measured in population 'life-years'. For example, outcomes based analysis prove that PAP smears significantly reduce incidence of cervical carcinoma. Finding undiagnosed disease without impacting patient longevity is the definition of a useless screening test. That doesn't mean that in limited cases, an ineffective test might detect the disease at an early stage and positively impact an individual's outcome, only that this is not the case for the entire screened population.

In this case, researchers have analyzed the data and determined the PSA is not a useful tool for screening the population. Isn't advocating continuing to spend money on a ineffective screening test so that providers save money 'a false choice'? And isn't a chief rationale for those who advocate a single payer system the elimination of waste?

A single payer system can only decrease costs by rationing care by restricting access. In theory this is a reasonable idea. We ration our food intake, luxury car consumption and yes high end audio purchases based on our unique personal circumstances including taste and financial resources. If health care is a 'right' that should be provided by the state to its citizens, does that include the right for all the health care an individual desires? Right now, if someone wants to purchase a useless screening test they are able to do so (provided they can get a script).

Moreover, if the state is providing your health care doesn't it have a profound interest and the moral obligation to try and change behaviors that add to the health care costs of society? And if you persist in these unhealthy behaviors, doesn't the state have the right and the duty to restrict health expenditures resulting from these actions?

I think this can be debated for months, not to mention years

For instance, if you want to talk about care costs: why should I who leads a healthy lifestyle, works out frequently, is within all acceptable health parameters, pay the same as as some fat slob who is on the see-food diet, sits for 23 hrs a day, and walks less than 1000 steps a day?

Speedskater · Oct 8, 2011

The new PCA3 test looks like a much better way to go.

Cleveland Clinic uses new prostate cancer screening test
http://www.cleveland.com/healthfit/index.ssf/2010/07/cleveland_clinic_uses_new_pros.html

PCA 3: New Marker Shows Promise as Helpful Urine Test for Prostate Cancer
THE BRADY UROLOGICAL INSTITUTE • JOHNS HOPKINS MEDICINE
http://urology.jhu.edu/newsletter/2010/prostate_cancer_2010_15.php

Phelonious Ponk · Oct 8, 2011

Jazzdoc, I will bow to your superior knowledge regarding the PSA. This, however, is simply inaccurate:

A single payer system can only decrease costs by rationing care by restricting access.

The greatest potential strength of a single payer health care system is the same as any large purchasing group, only much larger: it is the ability to negotiate pricing based on a the ability to deliver a huge amount of business. In the free market, this is called a Group Purchasing Organization. I work for a big one, and we manage to make almost 750 million a year while paying the other half of the savings to our customers. Of course in a government-managed single-payer system, there would be no reason for half the savings to go to the management company's shareholders, so it could be even more efficient. Personally, I think the best "health care reform" would be a non-political government-operated GPO set up to negotiate and purchase insurance and healthcare on behalf of the American people. Let all the insurance companies and redundant hospitals and clinics stay in business as long as they can compete.

The second greatest potential strength of a single payer system is the elimination of the mass of inefficiency that has created entire sub-industries around health care providers seeking insurance payment while insurance providers avoid it. It is not only horrendously expensive, as I'm sure you know, it has driven more than a few good doctors out of the profession. The cost of malpractice insurance and litigation pales in comparison in most practices.

And none of that has anything to do with rationing anything.

Tim

jazdoc · Oct 8, 2011

Phelonious Ponk said:
Jazzdoc, I will bow to your superior knowledge regarding the PSA. This, however, is simply inaccurate:

The greatest potential strength of a single payer health care system is the same as any large purchasing group, only much larger: it is the ability to negotiate pricing based on a the ability to deliver a huge amount of business. In the free market, this is called a Group Purchasing Organization. I work for a big one, and we manage to make almost 750 million a year while paying the other half of the savings to our customers. Of course in a government-managed single-payer system, there would be no reason for half the savings to go to the management company's shareholders, so it could be even more efficient. Personally, I think the best "health care reform" would be a non-political government-operated GPO set up to negotiate and purchase insurance and healthcare on behalf of the American people. Let all the insurance companies and redundant hospitals and clinics stay in business as long as they can compete.

The second greatest potential strength of a single payer system is the elimination of the mass of inefficiency that has created entire sub-industries around health care providers seeking insurance payment while insurance providers avoid it. It is not only horrendously expensive, as I'm sure you know, it has driven more than a few good doctors out of the profession. The cost of malpractice insurance and litigation pales in comparison in most practices.

And none of that has anything to do with rationing anything.

Tim

Wow, your GPO sure sounds like a monopolistic entity whose purpose is to use purchasing power to lower costs.

I may have to go downtown and protest!

Tim, every President since Johnson has promised to reduce fraud and waste in government generally and Medicare specifically. Waste and fraud isn't a bug, it's a feature. There are numerous examples of how a government run monopolistic organization with political, rather than profit motive performs. Indeed President Obama cited the Post Office as a model for how his health care plan would work. Yes, THAT paragon of efficiency and customer service that we call the Post Office. You know, the one billions of dollars in losses and planning to raise prices and decrease services. But the government can do worse; witness Fannie and Freddie. If there is an example of an efficient government monopoly, I'd love to hear more about it....Recalls the old joke about "why is there only one anti-trust division?"

Glad you note the burden that malpractice and litigation adds to our system. But did you know that malpractice reform is specifically excluded from the "Affordable Healthcare Act"?

Phelonious Ponk · Oct 9, 2011

jazdoc said:
Wow, your GPO sure sounds like a monopolistic entity whose purpose is to use purchasing power to lower costs. I may have to go downtown and protest!

Tim, every President since Johnson has promised to reduce fraud and waste in government generally and Medicare specifically. Waste and fraud isn't a bug, it's a feature. There are numerous examples of how a government run monopolistic organization with political, rather than profit motive performs. Indeed President Obama cited the Post Office as a model for how his health care plan would work. Yes, THAT paragon of efficiency and customer service that we call the Post Office. You know, the one billions of dollars in losses and planning to raise prices and decrease services. But the government can do worse; witness Fannie and Freddie. If there is an example of an efficient government monopoly, I'd love to hear more about it....Recalls the old joke about "why is there only one anti-trust division?"

Glad you note the burden that malpractice and litigation adds to our system. But did you know that malpractice reform is specifically excluded from the "Affordable Healthcare Act"?

The postal service, which has been killed by alternative technologies, is a bad example, but your point is taken: Big government programs are in efficient. Here's the part that's always left out of that argument: Big is inefficient. Period. Let anything grow large enough -- government, business, non-profit, it doesn't matter. If it gets big enough, it grows many dim corners for corruption, inefficiency and plain laziness to hide. It is inevitable. That doesn't make the scary idea that "a single payer system can only decrease costs by rationing care by restricting access" accurate and it doesn't mean there aren't some things, big, inevitably inefficient things, government can do that the private sector can and will not.

My son an I watched Minority Report the other night and at one point he asked when I thought we would have that kind of technology. I thought about that for a moment and then said, the small stuff? a few decades. The big stuff? Maybe never. It would require massive, unprofitable infrastructure projects. And we have, in the last 50 years, decided that government can't do anything, so we will only get what business - whose vision is mostly focused a quarter forward and has a maximum reach of five years - will do. Will we ever build another dam, another interstate highway system, another space program? Only if it is military.

I think we've talked ourselves into a mediocre future based on a notion of efficiency that does not exist.

Tim

FrantzM · Oct 9, 2011

Phelonious Ponk said:
The postal service, which has been killed by alternative technologies, is a bad example, but your point is taken: Big government programs are in efficient. Here's the part that's always left out of that argument: Big is inefficient. Period. Let anything grow large enough -- government, business, non-profit, it doesn't matter. If it gets big enough, it grows many dim corners for corruption, inefficiency and plain laziness to hide. It is inevitable. That doesn't make the scary idea that "a single payer system can only decrease costs by rationing care by restricting access" accurate and it doesn't mean there aren't some things, big, inevitably inefficient things, government can do that the private sector can and will not.

My son an I watched Minority Report the other night and at one point he asked when I thought we would have that kind of technology. I thought about that for a moment and then said, the small stuff? a few decades. The big stuff? Maybe never. It would require massive, unprofitable infrastructure projects. And we have, in the last 50 years, decided that government can't do anything, so we will only get what business - whose vision is mostly focused a quarter forward and has a maximum reach of five years - will do. Will we ever build another dam, another interstate highway system, another space program? Only if it is military.

I think we've talked ourselves into a mediocre future based on a notion of efficiency that does not exist.

Tim

I agree ...

Steve Williams · Oct 9, 2011

Man, I went to bed thinking we were talking about prostate screening and wake up to find talk about building dams and highways.

Phelonious Ponk · Oct 9, 2011

Steve Williams said:
Man, I went to bed thinking we were talking about prostate screening and wake up to find talk about building dams and highways.

Maybe not so different, Steve. If we're going to get big things, things that are either not profitable, or will take years to pay done, we can't count on the private sector to do it, and we may have to accept the inefficiencies of government programs working toward an objective other than ROI. Dams and roads are a great example, but so is medicine. Why would the big pharma companies make the a huge investment in curing a disease, knowing it won't pay for years, when there is so much to be made now from another cure for baldness or another erectile dysfunction pill?

The answer we must face up to is they won't. The profit motive is not the best motive for everything and you can't write policy, or even good political philosophy, on a bumper sticker. You have to understand the nuance. You have to understand that there is nuance.

Tim

jazdoc · Oct 9, 2011

Phelonious Ponk said:
Maybe not so different, Steve. If we're going to get big things, things that are either not profitable, or will take years to pay done, we can't count on the private sector to do it, and we may have to accept the inefficiencies of government programs working toward an objective other than ROI. Dams and roads are a great example, but so is medicine. Why would the big pharma companies make the a huge investment in curing a disease, knowing it won't pay for years, when there is so much to be made now from another cure for baldness or another erectile dysfunction pill?

The answer we must face up to is they won't. The profit motive is not the best motive for everything and you can't write policy, or even good political philosophy, on a bumper sticker. You have to understand the nuance. You have to understand that there is nuance.

Tim

Tim you don't know how right you are...

How can you get a dam built when environmentalists oppose everyone of them? Did you know we've take down more dams than we've built in the last decade? Same sad story for developing our own energy resources. Ironically, these are typically union jobs...

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