Word leaked late last week that the US Preventive Services Task Force (USPSTF) will recommend against prostate cancer screening with the prostate specific antigen. The evidence has been piling up for years that routine PSA screening doesn’t save lives – and the cost, morbidity and early death from treatment, and incontinence and erectile function problems caused by this screening are enormous. This is the link to the USPSTF draft recommendation, which rates prostate cancer screening a “D” (moderate or high certainty that the intervention harms, has no benefit, or harms outweigh the benefits).
The problem with prostate cancer screening is not only that there are many false positives. More importantly, there are many true positives that find cancer that would have had no impact on the patient’s life span or quality of life. A man whose prostate cancer would never have hurt him who has this treated is always worse off! The scientist who discovered PSA, Richard Ablin, editorialized against its use in screening in 2010.
Prostate cancer treatment is big business, too. Urologists and radiation therapists make a substantial portion of their income from prostate cancer treatment, and hospitals and physician groups have made huge capital investments in IMRT (intensity modulated radiation therapy) and even proton beam therapy centers.
Shannon Brownlee, author of “Overtreated” (see bottom of web page for book description) has a thoughtful and well-timed article in the New York Times Magazine today about this difficult issue. She asks “Can Cancer Ever Be Ignored?” She reports that the USPSTF was ready to release its finding on PSA screening in 2009 – but the blowback from the suggestion that year that mammography should not be routinely recommended for women between 40-50 delayed the recommendation. It was again delayed before the 2010 midterm elections – and even now the report was put out in draft form only after the content was leaked in the press.
This draft recommendation is finally published even as a separate investigation suggests that 40% of the cancer screening ($1.9 billion) services paid for by Medicare are medically inappropriate. This report only considered PSA screening inappropriate in men over 75. If all PSA screening was considered in appropriate, the portion of cancer screening that is inappropriate would be substantially higher.
There are some screening tests that improve the quality of health care – including pap smears and mammograms for women between 50 and 69. There is evolving evidence that CT scans might appropriate for screening those at high risk of lung cancer, although the literature on this is not yet fully settled.
It’s reassuring to think we can save lives (and money) by screening. This is true less often than we would wish.
PSA Scorecard
$3 billion spent on PSA screening annually
1 million men treated with surgery, radiation therapy or both who would not have been treated without PSA testing
5000 deaths shortly after surgery
10-70,000 major complications
200-300,000 cases of impotence, incontinence, or both