USPSTF – It’s About Time

The numbers are stark. According to the United States Preventive Services Task Force, for every man whose death from prostate cancer is prevented through PSA screening, 40 become impotent or suffer incontinence problems, two have heart attacks and one a blood clot. Then there’s the psychological harm of a “false positive” test result, which is 80 percent of all “positive” tests. They lead to unnecessary worry, follow-up biopsies, physical discomfort and even harm. Final grade: D.

Three men close to me have been diagnosed with prostate cancer late in life. Each was around 70. My dad, already in throes of advancing Alzheimer’s disease, did what the doctor ordered (actually, I suspect my mom told my dad to do what the doctor ordered). He had surgery. And for the last six years of his life, which until his final three months was at home, she cleaned up after him because of his incontinence. My neighbor made the same choice. He quietly admitted to me one day that he suffers from similar symptoms, but he is grateful because he believes his life was saved by the operation. And my friend Arnie? I’ve written about him in this space before. He was diagnosed at 70, and being a psychiatrist with a strong sense of his own sexual being, understood the potential tradeoffs. He decided to forgo treatment. He died a few years ago at 90. I never learned the cause.

So what does it mean that PSA testing gets a D rating?

If you want the test, or your doctor performs it routinely, your insurance company may not pay for the test. It won’t have to since the Affordable Care Act says prevention services must be rated either A or B to warrant automatic coverage. Yet I wouldn’t worry if you’re a symptomless man who is hellbent on getting this unnecessary test. Three insurers told the Washington Post yesterday that they will continue to pay for the test if it is ordered by a physician. I can’t imagine Medicare cutting off payment, either. The wary bureaucrats at CMS have no interest in wading into a fight with the “Evidence? We don’t need no stinkin’ evidence” crowd.

I predict that you’ll see no change in clinical medical practice from this pronouncement by USPSTF. Physicians in community practice will continue to routinely screen men between 50 and 75. Millions will continue to receive unnecessary treatment. A few thousand lives each year will be saved. Will that justify the harm — including premature deaths — caused by the false positives? We’ll never know. Because those who experience those harms will suffer in silence. After all, they’re men.

Merrill Goozner has been writing about economics and health care for many years. The former chief economics correspondent for the Chicago Tribune, Merrill has written for a long list of publications including the New York Times, The American Prospect, The Washington Post and The Fiscal Times. You can read more pieces by him at GoozNews.

1 reply »

  1. Mr Goozner,
    I feel that your opinion is very misguided. I would think that someone who has written on health care for “many years” would have done a little more research on the subject rather than assuming that the USPTF knows best. Prostate cancer is the 2nd leading cancer in men in the U.S. How could someone educated in health care believe that a man is better off not finding out if they have prostate cancer at an early age due to the possibility of developing urinary incontinence or impotence as a side effect of prostate cancer treatment? You referenced three people in your piece who were diagnosed with prostate cancer and two of them were treated. In both of those examples you focused on the side effects of the treatment. You even went so far as to insinuate that one of those that was treated would have been fine if nothing was done (noted by your comment that “he believed his life was saved by the operation”). Have you ever looked at those two examples from another perspective? What if your father or the other man weren’t treated at all? Advanced prostate cancer with eventual metastasis is no walk in the park. In fact, the symptoms and rapid progression of the cancer would make incontinence or impotence seem like a paper cut. And, speaking of incontinence, it is definitely a possible consequence to the surgical resection of the cancer, but urinary incontinence is also a very common symptom seen with advanced Alzheimer’s (stage 6 and stage 7). Prostate cancer, like many other cancers, is a difficult disease to treat. Not only are their potential debilitating side effects from the different medical treatments, but the organ itself is extremely difficult to access surgically. But, to disregard the screening process all together based upon treatment side effects is downright irresponsible. The fact that the USPTF recommends that PSA screening should only be done once a patient shows clinical signs/symptoms should be enough to confirm that they clearly have not thought this subject out far enough. With prostate cancer, once a patient presents with signs and symptoms, it is often already at an advanced state and even more aggressive treatment is needed by then. Finally, it blows my mind that you view this screening test as unnecessary. Numerous studies have shown its ability to decrease mortality, including the ERSPC trial which showed a 21% reduction in mortality amongst those aged 55-69 (which the panel seemed to acknowledge in their report, but oddly misinterpreted the results). I hope that you find it in yourself to see that the PSA screening test is invaluable tool in the work-up of diagnosing prostate cancer. The treatment options will continue to grow and improve, and throwing out a harmless test due to cost is just dangerous.