A highly qualified “thank you” to Drs. Welch and Albertsen — maybe?

The prostate cancer patient community should be aware of an “op-ed” in today’s New York Times by Drs. Gilbert Welch and Peter Albertsen arguing that Medicare should continue to let individual physicians make their own decisions about the use of the PSA test for risk of prostate cancer.

Drs. Welch and Albertsen have long argued that there are few good data to support the use of the PSA test as a mass, population-based screening tool to be used regularly to test for risk of prostate cancer in all men. However, as is clear in the referenced “op-ed”, this does not mean that they think using the PSA test in appropriate patients to assess risk for prostate cancer in those patients. Indeed, they state that

we are not comfortable rewarding doctors for withholding a test that could help some men. Screening is a gamble: There may be a few winners who win big (avoid a cancer death), but there are often many more losers (patients who go through false alarms, subsequent testing and unneeded treatment). There is no single formula to solve this equation; individuals in the same situation can look at the same data and legitimately make different decisions. When it comes to medical ethics, patient autonomy is about as fundamental as it gets.

On the other hand, Welch and Albertsen clearly state that they believe that Medicare should no longer pay for PSA testing because the cost is low and that if patients have to pay for this test themseleves it would make them think harder about whether the risks are worth the possible benefits:

… screening is a choice. Medicare should not penalize doctors for ordering PSA tests, but it should make sure it is not giving the test away free. Requiring men to bear the small cost of the test is not a punishment, it’s a motivation for them to consider the screening decision more carefully. Not only does the test have important implications for adverse health outcomes in the near future, but it also has near-term implications for some serious out-of-pocket costs from potential follow-up care.

This appears to reflect a perception among more affluent members of our society that would have profound effects for the poorer ones. It utterly ignores the fact that many families make decisions about things like whether to have a PSA test based on whether it is going to affect whether they will have to forgo a meal or some other necessity, and not on whether they actually need such a test. If one has never been in such a position, it tends not to occur to one that this is even a significant issue. A lot of older men in America are, in fact, in such a position.

So, we thank Dr. Albertsen and Dr. Welch for their clear message that Medicare should not be telling doctors that they should be monitored (and potentially “punished”) for using the PSA test to assess risk of prostate cancer in appropriately identified patients. However, we completely disagree that Medicare should stop covering the costs of the PSA test for those men who need to have one done. And last but by no means least, we would encourage Medicare to provide some rather more constructive guidance to the primary care medical community over which men > 65 years of age are actually good and appropriate candidates for PSA testing. It is certainly not all Medicare-eligible patients!

16 Responses

  1. It is hard for me to see how a real world GP would make sense of any of this. In the current environment, a GP (possibly along with a physician’s assistant) are likely running over 40 patients a day through the practice. A relatively healthy guy might actually see the doctor a total of 15 minutes in a year (if he is getting an official physical). There might be a hastily filled out family history on file. Patient autonomy doesn’t mean much unless you have an educated patient. With everything else a doctor might be looking for, would he/she really have time to discuss whether the patient should/should not get a PSA test? I am a regular reader of this web site, and I’m not sure if I should be getting an annual PSA or not. (I do know, at least, that I wouldn’t jump into any other decisions based on PSA test results alone). I had a physical a few months back, and the PSA test was automatically ordered. My company insurance paid for it. My doctor also started ordering vitamin D tests a few years back. The insurance does not pay for that. I suppose the dotorc can be confident that his female patients should not get a PSA test. Beyond that, he’s gotta be scratching his head.

  2. Well said, Sitemaster … hear, hear!

  3. If a man undergoes unneeded treatment for a low-risk prostate cancer, that is a bad medical decision, not the fault of the test. It is a poor workman who blames his tools.

  4. The authors of the Op-Ed are Fundamentally Ignorant

    I have read the op-ed, and, while glad they are opposed to another valueless burden on physicians, was immediately aware that these two doctors are rather ignorant of key realities in the field of prostate cancer. Here are some of them:

    Active Surveillance (AS) — AS is clearly surging in popularity after being proven effective and safe by clinical series at a number of leading institutions, with long-term follow-up at some of them, yet these two doctors do not even mention active surveillance. AS basically solves the problems they are concerned about.

    The Old Escaping Cell Myth — The authors use the bird, rabbit, and turtle analogy for the threats posed by aggressive, concerning (they use the word “treatment” meaning treatment can help), and insignificant, basically indolent prostate cancer. Their words convey the belief that once a few cells have escaped the prostate in a bird-like (aggressive) case of prostate cancer, no cure, or by implication long-term effective control, is possible: “… But the birds have already flown away. They are the most aggressive cancers, the ones that have already spread by the time they are detectable, the ones that are beyond cure. …” They imply that PSA testing, including informed testing, is not helpful in these cases; indeed they write about the rabbits, but not the birds: “… These are the cancers we hope to control with early detection.” We survivors of challenging cases know that is not true! Early informed testing is vitally important for us!

    The Value of the US Preventive Services Task Force — The authors take their recommendation basically against PSA testing at face value, accepting the Task Force’s blundering view that the recommendation is supported by science, when in fact, as we know, the science is on the side of informed testing.

    Thanks, Sitemaster, for keeping us aware of the state of play of real knowledge of prostate cancer in the medical communities.

  5. Them worried about doctors being punished? Give me a break!

    What about feeling worse for those that die of prostate cancer these days? These doctors will not get my thanks while they openly advocate the USPSTF guideline instead of a more logical use of PSA testing by baselining those that may benefit by the test. They continue to ignore the reduction in prostate cancer deaths while supporting the unproven notion that 40% of those diagnosed are over-treated…

  6. Dear Jim:

    (1) To suggest that Drs. Welch and Albertsen are “rather ignorant” about issues related to the diagnosis and management of prostate cancer appears to mer to indicate your ignorance rather than theirs. You may disagree with their opinions, but these are two researcher-clinicians who have spent years studying this subject. Indeed, it was Albertsen’s work in the mid 1990s that set the table for the introduction of active surveillance in the first place.

    (2) The question of whether mass, population-based screening does or does not lead to a real survival benefit is actually not proven at all. That is again your opinion and not one held by the vast majority. The role of individual testing of st risk individuals is a whole different question.

    One can disagree with Drs Albertsen and Welch on many grounds, but they are quite certainly entitled to their opinions and their is no question about the status of their education on the subject. The bird, rabbit, turtle analogy as presented in their op-ed is not some sort of absolute truth. It is a generalization, and you know that as well as they do.

  7. Dear Ralph:

    It is inaccurate to state that Drs. Welch and Albertsen “continue to ignore the reduction in prostate cancer deaths”. They very explicitly called the massive decline in the initial diagnosis of men with metastatic prostate cancer to everyone’s attention in an article earlier this year in the New England Journal of Medicine (see here).

  8. Let’s see, reading the tea leaves of a PSA test proved beyond the ability of physicians in total to read responsibly, so much so that a virtual partial ban was imposed.

    Solution; hand it over to the layman to make their own choice. Their medical training is the best.

  9. Mike,

    In your response you cite Dr. Welch’s article accepting or clarifying prostate cancer deaths reduction here in the US. In such article he said:

    “Thus, prostate cancer destined to become metastatic appears to fit the Halstedian paradigm: steadily progressing disease that allows time for screening to find it at an earlier stage. It’s important to point out, however, that although such a stage shift is a prerequisite for screening to reduce mortality, it doesn’t by itself mean that mortality will reliably decline. For example, although the European Randomized Study of Screening for Prostate Cancer showed that PSA screening almost halved the risk of metastatic prostate cancer presentation, screening reduced the risk of death from prostate cancer only by about one fifth.”

    In the Welch/Albertsen op-ed they state:

    “That magnitude of harm might be acceptable if the other cancers caught by screening were mostly those that could benefit from early detection. Unfortunately, the cancers that often kill are those that have already spread microscopically beyond the prostate before screening. Consequently, prostate cancer screening, at best, has only a small impact on the prostate cancer death rate.”

    Are those explanations for the 40%+ reduction in deaths prostate cancer here? Is that a small impact? That even when men are living longer and thanks to the USPSTF less men are being tested with PSA these days. Still no “thanks” to them from me!

  10. Dear Ralph:

    I wrote the title to my commentary the way I did for a reason!


  11. I think there is a time shift that is not being addressed. Not long ago,

    PSA test = biopsy = treatment

    i.e., a one-way ticket with no layovers.

    Even if PSA testing returned to it’s highest levels, it is unlikely immediate treatment (or even biopsy, though that is still an unlikely candidate for a major reduction) would as definitely follow the result.

    Some progress at least.

  12. Doug Miller,

    I wanted to address your comment that time constraints get in the way of educating patients. What the AUA and ASCO recommended was that patients receive a patient decision aid. They have been specifically designed and validated for this purpose. Here’s a link to one such aid.

  13. Doug’s Dilemma – Whether to Get a PSA Test

    Dear Doug,

    To me this is so simple, and I would appreciate your feedback. What I point out to people asking whether they should get the PSA test is that the most important issue is whether you would be comfortable with safe and effective active surveillance (AS) if you were to be diagnosed with low-risk prostate cancer, as many men are. I mention that research has proven that AS is safe and effective for appropriate patients. If your answer is yes, you would be able to choose AS, then why would you not get the test? If you happen to be diagnosed with low-risk prostate cancer appropriate for AS, pursuing AS mitigates the risk of over treatment. If you need treatment, then it is not over-treatment. Some men have been misled into thinking that treatment for appropriate patients (those with higher risk) makes no difference, but that is not true, as you know doubt know from spending time on this site.

    Your thoughts?

  14. Ouch!

    Dear Sitemaster,

    I am a bit taken aback and puzzled by your response of January 8, 2016 at 9:06 am to my comment just preceding.

    I realize it is not collegial to refer to these doctors as “ignorant,” but as a patient whose life was threatened by ignorance of a GP who almost talked me out of my first and fateful PSA test, I am no longer patient or feeling collegial with letting ignorance off the hook. I do thank you for noting their accomplishments, though that makes me even more puzzled why they would clearly make the three mistakes I highlight and which I am convinced need to be spotlit.

    First –- Failure to mention and describe the crucial role active surveillance plays in the informed testing process. The authors do not mention active surveillance and seem oblivious to it.

    Second –- The Old Escaping Cell Myth. Yes, the analogy is a generalization, but do these authors not clearly imply that informed testing and treatment (if needed) do not help those with fairly aggressive cancers (the “birds” in their analogy in the op-ed)? In view of their background, I cannot fathom how they would take this stance. Really puzzled.

    Third –- Their bow to the US Preventive Services Task Force: Here’s what they wrote in the op-ed – “… Lots of people are hurt; few are helped. This is why the United States Preventive Services Task Force recommends against PSA screening ….” I believe we are in agreement that the Task Force was badly mistaken in its understanding of research and prostate cancer. How can the authors make such assertions? Yes, lot of people are hurt unnecessarily, but not when active surveillance is in the picture, as we know it should be. And for the authors to say that “few are helped” when there are about 30,000 deaths a year and a much greater number fighting quite advanced disease, let alone the kind of life-threatening but not hormone resistant disease that I and many others have faced, why, I am gobsmacked (or the writer’s equivalent). Really, how can they say such things? What would you call that if not “ignorance?”

    Considering these three gaping flaws, is that not a reflection of ignorance? I’m curious what the authors would say in response on their own behalf to each of these issues. I am not at all in favor of ad hominem attacks, but I am all in favor of addressing key issues and facts no matter who the emperor is who is naked.

    Regarding your point (2), I suspect we are actually in agreement. You wrote: “(2) The question of whether mass, population-based screening does or does not lead to a real survival benefit is actually not proven at all. That is again your opinion and not one held by the vast majority. The role of individual testing of st risk individuals is a whole different question.” I recognize that there is not yet proof of a survival benefit to mass screening, which I too do not think is wise, though I think the European trial will give us an ever stronger indication to the already existing indication that even mass screening has a survival benefit. I believe we both expect that informed PSA testing would have a much more pronounced benefit than mass screening.

    If you have time to respond again, I would like your opinion how we patients should respond when we see prominent physicians taking erroneous stands. I do appreciate tact and would not address the concerns above so bluntly in an open meeting, but I would at least assert them. Frankly, having participated in a number of FDA hearings and other such ventures over the years, I have been convinced that tactful but straightforward talk is often necessary.

  15. Dear Jim:

    You may not like the opinions of Drs. Welch and Albertsen, but that doesn’t make them wrong and you right. What I may or may not think is irrelevant.

    The bottom line is that this is (and has been for years) and extremely controversial topic. It is not as simple as what people’s opinions are. It is also about how they express those opinions. What I am trying to tell you is that your language, based on your opinions and the way you interpret the available data, is actually just as ill advised as that of Drs Welch and Albertsen. You need to appreciate that there is a very reasonable argument that most (but not all) men of 65 and older (and especially those who have been being tested when they were less than 65 years of age with no sign of an elevation in the PSA) are not actually going to benefit from further PSA testing.

    Whether or not we should or shouldn’t provide free PSA tests for all those men then becomes a matter for debate. There is no “right” or “wrong” because that is, quite simply, a matter of opinion, and you can debate it all you like, but it won’t change the fact that opinion is the only issue.

  16. Agreeing with your comment of 1:44 am

    As always, you help me think, which is a good thing.

    I am convinced the line of thought you introduced about not testing some men of 65 and older as a wise strategy based on a certain favorable pattern of prior results is likely true. For the third time I went back to the op-ed, and this line of thought was not directly stated by the authors. In my view their op-ed would have been stronger if they had included it.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.

%d bloggers like this: