New US preventive care rules do NOT include prostate cancer testing

New rules for preventive care announced on Wednesday this week are designed to make selected services and screening tests available at no out-of-pocket cost to US consumers. However, prostate cancer testing will not be encompassed by these rules.

According to an article in the Washington Post, the rules require that health insurance plans must cover certain preventive services at no additional charge to their members. These services include:

  • Screenings strongly recommended (with a grade of “A” or “B”) by the U.S. Preventive Services Task Force (USPSTF)
  • Routine vaccines — including childhood immunizations through to tetanus boosters for adults
  • Well-baby visits to a pediatrician, vision and hearing tests for kids, and counseling to help youngsters maintain a healthy weight
  • Women’s health screenings, including tests to be required under guidelines that are still in development and not expected to be be announced until August 2011.

Mass, population-based prostate cancer screening (as opposed to individual testing) does not have a recommended “A” or “B” grade from the USPSTF, and despite what some would argue, The “New” Prostate Cancer InfoLink does not believe that there are data available to support a national recommendation that all men over a specific age should get annual PSA testing.

However, if there are going to be “women’s health screenings” required under guidelines still in development, there is most certainly an equally good argument for “men’s health screenings” — and for men with any significant degree of risk for or worry about prostate cancer we believe that regular testing should be encouraged based on sound guidance.

What we have here is a classic case of gender discrimination which women’s groups (and gay rights groups) would be howling about if it was being applied to them, and which most men won’t even notice. Men are at specific risk for disorders that have no impact or less impact on women (just as the reverse is also true). The lack of a national Office of Men’s Health within the Department of Health and Human Services means there is no advocacy within the Executive Branch of government for men’s health issues and it is shameful that we continue to practice this type of selective discrimination simply because men don’t make enough effort to act on this issue. Women simply don’t vote for legislators who don’t take a strong position on women’s health issues. Men don’t even ask their legislators whether they have a position on health issues at all — let alone men’s health issues.

Did you take action on this issue today?

Now the new rules do not mean that you won’t be able to get an annual PSA test if you need one. What they mean is that the amount that PSA test costs you will depend on your insurance carrier (as it always has to date). Men who have only minimal health insurance may therefore find that they have to pay the full cost of a PSA test. Those with better insurance would likely continue to get the test at no cost (except for the regular co-pay for the doctor’s visit).

12 Responses

  1. I think this discriminatory decision needs to be opposed. With over 200,000 diagnosed prostate cancer patients yearly, there should be enough men willing to write and demonstrate to change this decision.

    Does anyone know who should we contact to express our opposition?

  2. My guess is that you should start with the Hon. Kathleen Sebelius, who is the Secretary of Health and Human Services, with copies to President Obama, your Senators, and your Congressman or Congresswoman.

  3. As an eleventh year survivor of a challenging case of prostate cancer, doing very well, thank you, I’ve been in favor of informed screening ever since I was shocked by my diagnosis. However, in the early years of this decade my enthusiasm diminished as mass screenings with little education about the disease seemed to flush out patients with low- and very low-risk cases into the arms of over-eager surgeons and other doctors.

    I still doubt that such informed mass screening is worthwhile.

    However, there has been a sea change with the powerful emergence as active surveillance as a prime or go-to option for dealing with prostate cancer in men with low- and very low-risk cases. I’m convinced that coupling brief active surveillance information with screening will essentially do away with the over-treatment problem, making screening for prostate cancer a no-brainer.

    The USPSTF has no board members with significant (if any) experience treating prostate cancer. I’m convinced they simply fail to appreciate that prostate cancer is a slow-growing disease with a high survival rate, making clinical trials of customary follow-up duration almost useless for assessing the utility of screening. Even experienced doctors have been misled, as evidenced in the undue credibility accorded the PLCO and European trials intended to evaluate prostate cancer screening that were actually published in the New England Journal of Medicine last year, despite glaring deficiencies.

    I believe we need to find a way to communicate with the talented and dedicated board members and staff of the USPSTF so that they will become savvy enough about prostate cancer to see the enormous value of screening. Communicating with Congress won’t hurt either.

  4. Jim’s comments describe my input.

  5. As I said earlier this week. This type of policy will be what health care rationing looks like. Whether you believe population-based screening is of value or not, there’s no doubt that the lack of requirement for insurance coverage of PSA tests (and certainly more expensive screening tests) for those with significant risk factors will mean that the poorer you are the more likely you are to have your prostate cancer diagnosed and treated at a later phase with worse outcomes — either your life or your ability to live your life with the ability to control the basic of human functions.

    As a woman commenting on this thread, I would suggest this issue is a little more nuanced than women’s groups and minority groups screaming for their due. It’s worth remembering that advocacy groups for women and minorities came into existence in the first place because for decades (um, centuries, millennia) the knowledge and clinical practice of medicine was researched and articulated largely on how white, affluent-enough-to-seek-care men responded. Advocacy by those groups has been about being acknowledged at all, not about being favored.

    I don’t want to get into an argument about the relative value of humans based on the shape of their genitalia, the shade of their skin tone, or who they like to have sex with (found the homophobic reference really gross). That argument is a dangerous, dangerous diversion that allows those who value the almighty dollar over our lives to distract our attention with petty political skirmishes. I am suggesting that the fault line isn’t gender or race, the fault line is income and education.

    I also fear a more insidious impact of leaving prostate cancer screening out of coverage requirements. Leaving it out implies that it’s not truly a risk. It suggests that screening, even for those at high risk, is a luxury — more akin to a cosmetic treatment than a life at risk. So, over time, even those with health insurance will be less and less likely to be able to afford the costs or have ANY coverage for screenings for diseases of the prostate or anything else.

    If even high-risk men have to wait for affordable screening until they have a positive DRE, we all know a lot more of them will be a lot worse off than they would have been if the cancer had been caught when their cancer was much smaller.

    No man ANYWHERE with risk factors for prostate cancer should go unscreened because he can’t afford a test and/or doesn’t even know he needs to be tested. This is a simple matter of human dignity and human decency.

    The percentage of men who will eventually develop prostate cancer is staggering. Pretending like this very high probability doesn’t even exist will cost the lives or unnecessarily ruin the lives of people we all know and love.

    There’s an actuary rubbing his hands together with glee over this deal. I hope for his family’s sake he’s never the guy who would have benefited from a PSA, or PCA3, or biopsy. This is a shameful state of affairs.

  6. Homophobic? Odd!

    I (thought I) was praising gay people (and women) for their activism.

  7. The way I read the mail was indeed praising women and gays for their activism and chastising men for their lack of it.

    I don’t think not including PSA in the recommended screening is due to the desire to save money. If that was true, mammograms would not have been recommended either, in particular since a mammogram is more expensive than a simple PSA test. Also, PSA screening makes a lot of financial sense. When discovered early, prostate cancer treatment will require, in many cases (about 40% per current studies), only a relatively simple surgical procedure. Contrary to expensive radiation and hormone therapy that are required for treatment of advanced cancer.

    Why then not do PSA screening? No logical explanation is given by opponents, especially in view of the new studies that show a mortality decline of 50% for screened population compared to unscreened.

  8. Sitemaster is spot on re: male office of health. Who speaks for male-only problems?

    With males getting 50% cancer vs. 33% for females, we have a stronger need for better representation.

    We know that breast cancer is funded at a rate three times higher than prostate cancer. Yes, 5,000 males get breast cancer each year, but the majority of cases are in women.

    I am surprised that the FDA doesn’t require drugs to be tested on the separate genders unless they are gender specific.

    We know that prostate cancer hits blacks and hispanics harder and earlier then whites. They also represent a class that may be less able to afford any extra health payments. This racial discrimmination is unthinkable. Again, a male health department is needed to voice this issue.

    Male health issues can be different as in male vs. female heart attack symptoms. Males survive heart attacks better then woman (thought to be due to male’s larger mass).

    Cancer vaccines: HPV vaccine, does it work for men? STD’s different symptoms by gender? Genes by gender; color blindness in males as an example. The human genome project. Is it the same for both genders? Many unanswered questions that will improve healthcare for both genders.

    The question isn’t why don’t we have a male health department but how could we have gone this long without one?

  9. Ah but Reuven … the recently published data from the Goteborg screening trial showed no overall mortality benefit. It showed a prostate cancer-specific mortality benefit — not an overall mortality benefit. This is a very important factor in the overall equation.

  10. It’s true the Goteborg study showed prostate cancer-specific mortality improvement only, but that’s what PSA is about. Treating prostate cancer cannot result in overall mortality reduction. Can it? We still have to die. Don’t we?

  11. The cost savings doesn’t come from not providing the test. The cost savings come from delaying diagnosis and subsequent treatment.

    Rueven, of course, is right about the lower cost of preventive and early care than later care, to the extent that the goal is to provide care at all. We have a system notoriously “penny-wise, pound foolish.” Private, for-profit insurance companies want to save every possible dime they can, including the first possible dime to be spent. Inexpensive, effective preventive care is routinely excluded from coverage for all kinds of risks — even for highly curable or manageable diseases like diabetes and early heart disease (“lifestyle” diseases).

    Cancer, as a category of diseases, is relatively expensive to treat. I suspect there are those in the business of managing health care who would simply like to go back to a time where all cancers are like pancreatic or esophageal cancers — late diagnosis, an initial comparatively small expenditure of dollars, and soon the cost-problem is over (or, to be a little less gloomy, more like cervical cancer, where treatment is both inexpensive and generally fully effective).

    I encourage you to check out the cancer trends progress report.

    As a population, prostate cancer patients are in the top tier of cancers in terms of treatment costs. Perhaps it’s not so expensive to treat most individual men upfront, but so many men eventually get prostate cancer, and we’re now so good at keeping them alive, that from a profit-seeking/cost-management perspective, it’s just too costly to keep doing such a good job. There’s no money in it for the guys who ultimately demand to make money from it.

    Which brings me back to my initial point and an apology to our sitemaster. I’ll take your word that your intention was to be complimentary to breast cancer and HIV/AIDS (many of whom are not gay) activists for effectively drawing attention, and ultimately support, to their causes. I’m sorry I misinterpreted, but I do think it’s important to be hypersensitive to the risks of pitting those who need access to health care against each.

  12. Dear Reuven:

    The whole idea behind the trials of mass, population-based screening for prostate cancer is that you will diagnose the disease earlier enough to cure it in the men who are screened, and by curing it you will allow the men who are screened to live longer than the men who do not get screened (and therefore do not get diagnosed early enough to have curative therapy).

    If mass, population-based screening is not able to extend average overall survival by comparison with non-screening (which is exactly what the Goteborg trial showed), then why would we spend enormous amounts of money and effort carrying out PSA tests every year (or every 2 years in the case of the Goteborg trial) in millions of men over 50 (or 45, or whatever)?

    Of course we will all die in the end. It’s the only absolute certainty in life. The basic idea behind screening any population for any disease, however, is that it will, on average, increase the overall survival of the entire population (not just the men who get that disease). The Goteborg trial (to date) demonstrated that mass, population-based screening for prostate cancer does not achieve that — despite the fact that screening did indeed extend the disease-specific survival of the men diagnosed with prostate cancer in the screening arm compared to the non-screening arm. Critics of mass, population-based screening will, and rightly, state that this trial shows that the early detection of prostate cancer in the screening group in this trial did not, in fact, make a blind bit of difference to the average overall lifetime of these men compared to those who were not screened.

    It is really, really important in this to understand the difference between mass, population-based screening (which implies a recommendation for regular testing of every relevant member of a population) as compared to early detection of prostate cancer in men who have some reason to be worried about it. This is by no means a subtle distinction, but people often don’t appreciate the difference.

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