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Negative Evidence on PSA Screening Does Not Go Down Easily

By October 23, 2009

Questions about the potential harm of breast and prostate cancer screening are not new. In fact, in the past 12 months, more and more studies have come out concluding that PSA screening and mammography may overdiagnose patients. Most of the patients screened and confirmed to have prostate cancer do not go on to have aggressive, lethal cancers. Preceding that were years of debate in journal reports and medical meetings.

On Sept. 22, I described where the major MD organizations are on this issue, and how jarring it would be to envisage an upside to not getting screened.

So it didn't surprise me earlier this week when Gina Kolata's New York Times article punched up the issue and made Otis Brawley, MD, Chief Medical Officer of the American Cancer Society, sound like he spoke out of turn.

Brawley had this to say: "We don't want people to panic. But I'm admitting that American medicine has overpromised when it comes to screening. The advantages to screening have been exaggerated."

By late afternoon, the ACS' Brawley tempered the comment, and the next morning's paper ran a lukewarm piece with the headline "Benefits and Risks of Cancer Screening Are Not Always Clear, Say Experts."

Research has shown repeatedly that doctors don't know how to talk about potential over-diagnosis to their patients, and so they don't. When patients read these articles, they see the information as little more than coming out of personally charged individuals.

I wonder how much good Kolata's article did when she set the stage for a food fight, or alternatively, when the press buys the line put out by The Times the next day that readers may be too stupid or confused to get it.

Conflict over PSA screening has been simmering for a very long time. This week, it rose to a fever pitch. I wonder what it will take for evidence to prevail. The ACS clinical practice guidelines have been posted on its website for a very long time. Brawley reiterated ACS' position about the uncertainties of PSA screening in detecting clinically significant, aggressive cancers.

Even the flagship American Urological Association acknowledges the uncertainties of PSA screening and prominent urologists have expressed skepticism on broadcast news.

The press owes it to its readers to treat them like they are not watching a side show and tell the story clearly. Doctors owe it to their patients to discuss these difficult issues.

Comments
October 23, 2009 at 12:31 pm
(1) Deek says:

I agree Ms. Newman. The media sometimes do a disservice by glossing over significant findings about a variety of health issues.

How about writing about urological issues for people with disabilities? Your easy-to-understand columns could provide a valuable resource to those with disabilities and would help educate the general public.

October 23, 2009 at 12:52 pm
(2) Lisa says:

Overscreening not only leads to unnecessary interventions, it can cause unnecessary anxiety and unnecessary costs. driving up insurance premiums for those fortunate enough to have insurance.

Few doctors have the skills to communicate with patients. Gina Kolata’s article will do little to improve that. Doubting Thomas patients are not what the doctor orders.

October 23, 2009 at 12:52 pm
(3) urology says:

Your comment is well taken. This blog is pretty new to me. Basic urinary problems faced by the disabled should be addressed and I will try to do that in the near future.

October 23, 2009 at 1:26 pm
(4) urology says:

One problem with talking to your doctor is that many stick with the way they were trained, and for generations they have been trained to do screenings. The costs of false positives and oversensitive positives was downplayed. So get a good doctor to talk to.

October 23, 2009 at 2:08 pm
(5) Norman says:

Maybe the reason doctors give PSA tests to their patients so much is that Daniel Merenstein lost a malpractice case after he explained the pros and cons of PSA testing to a patient who declined to take the test.

JAMA. 7 January 2004;291:15-16. A Piece of My Mind: Winners and Losers, Daniel Merenstein. http://depts.washington.edu/gim/calendar/hmcjc_abstracts/JCJul04Article1.pdf Merenstein counseled a 53yo man on PSA testing, and the patient declined. Later, the patient was diagnosed with Gleason 8 PCa. The patient sued for malpractice. The plaintiff’s attorney argued that Merenstein should have ordered a PSA test without discussing it, because it’s the standard of care. “During closing arguments the plaintiff’s lawyer put evidence-based medicine on trial. He threw EBM around like a dirty word and named the residency and me as believers in EBM, and our experts as the founders of EBM. He defined EBM as a cost-saving method and stated his belief that the few lives saved were not worth the money. He urged the jury to return a verdict to teach residencies not to send any more residents on the street believing in EBM.”

Why does a doctor even have to ask? Wouldn’t every man rather have surgery that would leave them with sexual impotence and urinary incontinence for the rest of their lives than face a 5% chance of dying from prostate cancer at age 85?

October 23, 2009 at 3:27 pm
(6) Andrew says:

Valuable post.

Whenever I see my doc, I feel like I have to bring along a stack of journal articles and US Preventive Services Task Force recommendations in order to resist the pressure to test, test, test.

October 23, 2009 at 3:45 pm
(7) nancy says:

The issues of overscreening for cancer and the inability or unwillingness of doctors to honestly discuss the pros and cons with their patients are due in part, I believe, to the threat of malpractice, whether or not they have an investment in the equipment that is used, and what the insurance companies will pay for.

October 23, 2009 at 5:00 pm
(8) Lisa says:

Nancy said:
“The issues of overscreening for cancer and the inability or unwillingness of doctors to honestly discuss the pros and cons with their patients are due in part, I believe, to the threat of malpractice, whether or not they have an investment in the equipment that is used, and what the insurance companies will pay for.”

You are right about that, Norman gave a good example. A friend in France reports on a woman who was not screened for a rare cancer she was later diagnosed with.

October 23, 2009 at 7:30 pm
(9) Norman says:

You can always get an accurate, scientifically rigorous, reliable answer from the Cochrane Collaboration.

Unfortunately the answer is, nobody knows.

October 23, 2009 at 10:16 pm
(10) sandy says:

Hard to know what tests are worth taking. It is good that more light is being shone on the issue. The manufacturers of these diagnostic tests make money in any event.

October 25, 2009 at 10:04 pm
(11) Norman says:

There was a good article in the latest NEJM about prostate cancer. Maybe Laura can tell us about it.

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