Readers know that I am skeptical of medical practices that defy logic, or as we say in the business, evidence. Among the most controversial issues that beguile all of us (patients and docs) is this business about the PSA test.
A loyal reader sent me a doctor-written column with the provocative headline “My Patient, Killed by The New York Times.”
First, keep in mind that the website that posted this, Mediaite, is all about the media covering (really fawning and dishing) itself. The purpose of this story, with its provocative headline, sad outcome, and mea culpa tone, is to generate “buzz.”
Then understand that this is a story of one patient who made an informed decision to forego PSA testing, based on the fact that he was an intelligent person without symptoms who’d read the literature (or at least responsible press coverage of said evidence). He did not want to open the Pandora’s Box (literally: crapshoot) that is PSA screening.
Yes, he wound up with advanced prostate cancer and subsequently died. Had he had his prostate removed or radiation to ablate his cancer, and wound up with horrible side effects (impotence, incontinence) would he value the trade-off?
I offer you the counter-anecdote of Ted, who in a discussion with me, insisted that he get a PSA test because his heroes Joe Torre and Norman Schwarzkopf told him to. When it came back at 4.10 ng/dL (threshold 4.00), he went for biopsy (what else to do?) which showed low grade, gland-confined prostate cancer. Fearful of the “C” word, he couldn’t live with the idea of doing nothing (“watchful waiting”) about his cancer. So he chose external beam radiation, with the hope that it would be less damaging than radical surgery.
What is radiation proctitis? Is that when your rectum is severely burned as collateral damage by the radiation beam that’s targeting the prostate, and you wind up with rectal pain and bleeding for years? Why yes, it is. That’s in addition to the impotence and loss of bladder control that Ted experienced and had hoped to avoid by foregoing the surgical knife.
Or George, who dutifully came yearly for his digital rectal exam, got his PSA, and when his biopsy showed low grade prostate cancer, opted for surgery. At 64, he told me he’d have rather be dead than live wearing adult diapers his incontinence now thrust upon him.
PSA is a contentious issue. There will always be anecdotes showing that one approach or another is WRONG. The “retrospectoscope” is always 20/20.
But when an entire industry has evolved to profit off of “advanced” treatment for prostate cancer and innocent people are harmed in the process, I get angry.
I took an oath to do no harm. Treatment that causes more harm than the disease it’s designed to cure is tragic.
People will read this post and be outraged. So let me be clear: I’m not saying that NO ONE should get a PSA to screen for prostate cancer. That genie has left the bottle decades ago. I’m saying that the medical and disease-mongering industries owe it to men to be more forthcoming about the risks, benefits, and alternatives to screening.
I try my hardest–and I’m countering years of ‘public awareness’ campaigns. Just ask my Dad, who at not-quite 75 keeps getting the darn PSA year after year despite my advice to stop. “How can a test that detects cancer be harmful?” he always asks me.
John H. Schumann, MD is a general internist and medical educator at the University of Oklahoma School of Community Medicine in Tulsa, OK . He is also author of the blog, GlassHospital (@GlassHospital), where this post originally appeared.
Categories: Uncategorized
The Choosing Wisely campaign does not target PSA testing, except to recommend against the use of antibiotics for elevated PSA values in the absence of urinary tract symptoms.
see pp. 41-42
http://www.choosingwisely.org/wp-content/uploads/2013/02/Choosing-Wisely-Master-List.pdf
The ABIM and the AUA (the American Urological Assn.) co-authored the recommendations in this domain. I think the AUA is too far in favor of PSA testing for too long to turn back on it now.
Your patients sound lucky to have you.
Those are discussions I suggest to family members, etc., if the subject comes up. One person said, “Oh yeah – I forgot you didn’t like doctors.” Really – far from the truth! But I don’t think it’s fair to doctors to abdicate responsibility for making life or death decisions for their patients. And cost decisions for that matter – which if people have to pay for it themselves can feel like life or death.
Is PSA a test that the new campaign Choosing Wisely (dot org) will be targeting for more patient questioning? I always tell my blog readers to think about what the test is going to show–and if they had the disorder, would they do what was suggested? If not–maybe they don’t even need the test. Example: cholesterol. If you won’t take a statin for some reason (and there are some), then why have the test all the time? I suppose some people will think this is irresponsible. I once had a doctor ask me if I knew the term “noncompliant”? I said it had come up a time or two.
As a primary care doc, I find that having that discussion to try to give “broader understanding of its [PSA] pitfalls and consequences…” is tough in the time we have. BUT… I do it each time and I think most men have some sense that, a) this is a lousy test, b) it’s what we have right now c) not testing may be a better choice for more men and d) it can open a Pandora’s box. Then they make their decision
I’m saying that PSA testing should be discouraged.
Unless it can be done with broader understanding of its pitfalls and consequences: men need to know that an ‘elevated’ PSA will most likely result in biopsy, and subsequently, many more unpleasant and life-altering choices.
Too often it’s just treated as check-box, without meaningful discussion.
I’m not as informed about prostate cancer as I should be and the article left me a little confused. Is the author saying that PSA tests should be discouraged or is he saying that the PSA is okay but ‘watchful waiting’ should be the standard approach to care unless further testing/family history/whatever indicates that more aggressive approaches like surgery or radiation are needed?
PSA screening is a lot like mammography. We have a test that is not very good; lots of false positives, some false negatives.
“Primum non nocere” – First do no harm. Hard to follow that maxim when the man who has an elevated PSA or the woman who has an abnormal mammogram says- “do everything”.
At least with prostate CA, some of the psychosis that surrounds breast CA is absent.
An elevated PSA test prompted my knee jerk about 15 years ago, 8 biopsy samples…nothing found.
Now I am tuning 70 and my philosophy is that the clinical indications are that this disease can kill me over about 15 years…I will have one more PSA the only one I have had in 15 years…but after that what will be will be!
“anonymous media critic”
I teach my students to ignore “anonymous anything”…
@anonymous, look at the story he’s referring to:
“I read The New York Times every day and I must say that when it comes to health care issues it can be confusing. They are either writing on the over-utilization of unnecessary tests or the underutilization of necessary tests.”
This means that the paper is covering both sides of the story. There’s nothing unprofessional about that.
Great post – I hope everyone reads it.
Makes you wonder what would happen if journalists were opened up to malpractice liability for opinions that are ill-informed, failure to follow proper professional guidelines, incompetent work and ethical lapses …