Health, technology, cost, and the PSA test

An editorial commentary printed in today’s New York Times is focused on an estimate by the US Congressional Budget Office that “an astonishing half or more of the increased spending for health care in recent decades is due to technological, surgical and clinical advances.”

In making the point that many advances in health care are clinically valuable and economically cost effective and that some aren’t, the editorial implies that the PSA test is an example of a technological advance that is neither clinically valuable nor economically cost effective. (To be fair, the article does not state this explicitly.) The Times uses the OpEd written by Richard Ablin some months ago as documentation to support this viewpoint.

Whatever one may happen to think about the value of the PSA test as a mass, population-based screening test for prostate cancer, what is most certainly true is that any fault lies not with the test itself but with how we use the test and how we apply the results when we get them. From a time in the late 1980s and early 1990s, when the PSA test was, most certainly, an extremely valuable test to detect risk for prostate cancer in a previously untested population (US males of 50 and over) at significant risk for prostate cancer because they had never been tested, it has become a test promoted as an annual screening mechanism for any man over 40 years of age — and the data to support this broadest of possible uses is definitely on shaky ground. However, we can not afford to throw out the baby with the bath water.

For men with known risk factors (age, ethnicity, genetic predisposition, family history), the PSA test is the only way we have to monitor that risk. Indeed, preliminary data from a large study just published in Europe suggests strongly that the PSA test is a very appropriate screening test for prostate cancer in men known to have the BRCA1 and BRCA2 genes. By contrast, it is becoming evident that most men of 40 and over do not need an annual PSA test (just as they don’t need an annual screening test for colon cancer, where the annual screening period is normally every 5 years).

There are three things that need to happen for Americans to get a better grasp on the value of PSA testing:

  • The first is a better appreciation for risk. If you have no good reason to believe you are at risk for prostate cancer, it is open to question whether you need a PSA test annually. What we do need to to know is whether the appropriate frequency for PSA testing in men with no known risk factor is every 2, 3, 4 or 5 years. (Recent data from the Göteborg study in Sweden certainly suggest that every 2 years is effective, but we really don’t know whether that is the best possible option.)
  • The second is more sensible responses to the results of PSA testing. What are the data that should trigger the need for a biopsy that is liable to find not just any prostate cancer at any age, but any prostate cancer that is likely to be clinically significant in the lifetime of a specific patient.
  • The third is a widely accepted, data-based mangement paradigm for early stage, localized prostate cancer that is inclusive of the very real value of expectant management, so that patients with apparently low- and very low-risk disease are not rushed into the operating room or the radiation suite when it would be better medical practice to monitor them for the possibility of higher risk for at least a period of time.

Whether or not we are “over-diagnosing” prostate cancer is an arguable question (particularly if you take the viewpoint that the diagnosis of the condition is entirely justifiable). What most certainly is the case, however, is that we have been over-treating men with low- and very low-risk disease. Excessive use of the PSA test may well be a factor that has lead to over-treatment, but that over-treatment is something that we can control. Rather that just “trashing” the PSA test, we need to address the more fundamental problem which is a reflection of the decisions we make about the need for a PSA test in the first place in a specific individual at a specific point in time and how we react to the test results when we get them.

And of course what we really need more than anything else is a much better test for risk of clinically significant prostate cancer — just as soon as is humanly possible.

3 Responses

  1. Amen to your conclusion, Sitemaster!

  2. For a long time many of us have been broadcasting that the PSA test is about information, not treatment — so we thank the sitemaster for endorsing this message.

    The assessment of one’s own risk as a filter for taking a PSA test is tricky. African american men, or men with hormonal cancer in their family should test annually from an early age … but what about other ethnicities who have no knowledge of their family history?

    Of the 200,000+ annual prostate cancer diagnoses (218,000 projected for 2010), somewhere between 20,000 and 30,000 men have locally advanced or advanced prostate cancer. This number is comparable with the number of men annually diagnosed with leukemia, oral, rectal, or pancreatic cancer; two to three times the number of men diagnosed with brain, thyroid, stomach and liver cancer, and not that much less than melanoma or lymphoma. These men are at high risk of mortality if diagnosed late or when symptomatic; do we ignore them because some men choose to be over-treated as a result of poor medical advice?

    It is not the PSA test that is at fault for over-treatment — nor should we put many men at risk of death because the medical system fails those who are over-treated. As a youngish man who was diagnosed with T4NxM1 disease (and who Chuck and I recently advised) asked me, “Why did my doctor not recommend a PSA test?”

  3. I concur with those who have posted so far … including the Sitemaster… I recall this discussion we have had on various occasions, Mike. …Three cheers from me.

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