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PSA and Prostate Cancer Screening Doubts

Posted Sep 07 2008 8:10pm
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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