By Virginia A. Moyer, M.D.
Amid the many messages you will hear about screening for prostate cancer in the coming days, I hope these stand out most prominently: Science finds that there is at a best a small potential benefit from prostate cancer screening and there are substantial known harms. We need a better test, and we need better treatment options. We can do better.
The panel that I chair, the U.S. Preventive Services Task Force, has just issued a recommendation against screening men of any age for prostate cancer using the prostate-specific antigen (PSA) blood test. The draft of this recommendation was posted for public comment in October. Since then, we have read the many comments received, reviewed newly released evidence, and arrived at this conclusion:
Many men are harmed as a result of prostate cancer screening and few, if any, benefit. The evidence shows that at most 1 man in 1,000 screened will avoid a prostate cancer death over the course of 10 years, and in the best and largest study done in the U.S., no benefit was shown. Of the same 1,000 men screened, two to three will have a serious complication of treatment such as a blood clot, heart attack or stroke, or even death, and up to 40 will have erectile dysfunction, urinary incontinence or both. About 30 to 40 men in 1,000 will also have less serious but bothersome harms from a prostate biopsy, such as infection.
We need a better test, and we need better treatment options.
Cancer is a frightening word, but not all cancers are deadly. Prostate cancer is rarely aggressive enough to cause death within the course of a man’s natural lifespan. Three-quarters of men older than 80 and a third of men between ages 40 and 60 have cancer cells in their prostate, and yet men have only a 2.8 percent lifetime risk of dying from the disease. Currently, there is no way to know which men have a cancer that may benefit from treatment.
Until we have a better test and better treatment options, the USPSTF has recommended against screening for prostate cancer. Whether or not to be screened for any condition is a decision each person must make with his or her clinician based on individual values and preferences, but we are urging all health care professionals to be forthcoming about the facts around prostate cancer risk, the relatively small benefit of detecting the cancer, and the significant known harms of screening and treatment.
To be sure, there are gaps in the existing evidence on this topic. One particular area of concern is that African-American men have a higher risk of developing prostate cancer and dying from it. The same is true for those with a family history of the disease. There is no evidence to suggest, however, that these men have an increased benefit from current prostate cancer screening or that the balance of benefit and harms is any different for them. We need more research to improve the health of men at high risk for prostate cancer and to eliminate health disparities.
Some critics of our recommendation have suggested that we based our decision on an urge to cut costs for insurance companies and government programs such as Medicare. Cost is not a consideration in our evaluation of the scientific evidence. Our mission is to improve the health of all Americans by sharing evidence-based recommendations with them and empowering them and the clinicians who serve them to make informed decisions.
The members of the USPSTF are human; we face the same concerns and fears about health challenges that you do. This topic is not something we take lightly, and this decision was not reached in a cavalier fashion. It is based on science and rooted in the knowledge that while we all want to help prevent deaths from prostate cancer, we need to recognize that current methods of PSA screening and treatment of screen detected cancer are not the answer.
We can do better.
Dr. Virginia A. Moyer is chair of the U.S. Preventive Services Task Force, an independent panel of experts in prevention that reviews and makes recommendations for clinical preventive health services.
So DR. Moyer you recommend a 70 year old male with a Gleason score of 7+ to refuse treatment?
During my last physician visit, the doctor game me the ol’ Army prostate test, which I’ve not had in a while – and thank goodness.
“Things felt normal” was his verdict, but he then ordered (without my knowledge or permission) a PSA test anyway, for $109 on my bill.
As has been the case with every other PSA test, the results were negative.
A routine semi-annual visit that usually costs me about $100 out of pocket, over and above Medicare, this time cost $688. Even the clinic was embarrassed by the blatant profiteering involved, so the statement listed a $300+ “Medicare discount,” which I’ve never heard of before, and doubt really exists. That still left a balance of $329, instead of the usual $90 to $100 I have to pay.
I called to question the bill, and a couple days later got a call from the billing office (the clinic I go to doesn’t even do its own billing – they farm it out to someone else) to inform me that they’d cancelled the balance, so I was home free. I wasn’t going to look the proverbial gift horse in the mouth, so I graciously accepted their decision, but it simply points out – as if more evidence is needed – just how broken our health care system is.
To cover his and the clinic’s posterior, the doctor had ordered a test I didn’t ask for and wasn’t informed about, but which I (or taxpayers, through Medicare) would have to pay for. Total time for this $688 office visit was no more than 20 minutes, including 2 minutes spent actually using a stethoscope to listen to my heart and my breathing.
We can do much, much better. The current system rewards greed and inefficiency, not just for things like PSA tests, but in general.