U.S. News and World Reports surveys doctors about support for PSA screening

I also noticed that the answers to the "vote" at the end of the article, whether men should get the PSA test as a screening test for prostate cancer, are running overwhelmingly in favor of doing so: 88.6 percent saying yes at the time I read the article.

This is not a surprise. What does surprise me is that the "taskforce" so totally missed the important point. I am not naive enough to think that they were not influenced by "big bucks" insurance companies. However I guess I hoped that they still had their integrity. They were either bought out or given bad information that they chose to believe.

How did this influential group of doctors find themselves outvoted by their medical peers 80 to 1? How did they decide that PSA testing did not save lives? We guess that every male doctor in that group has had a PSA test. How hypocritical can they be ???

Predictable — urologists are in favor of much more PSA testing.  Join the line of urologists who have already commented similarly...

Read this excerpt fron a NY Times article from the first week in October:

At the heart of its advice is the startling finding that thousands of doctors in the United States have been doing many of their patients more harm than good. While the panel did not explicitly level such a charge, Dr. LeFevre said that the dangers of common treatments were what drove the members to recommend against screening. “If you’re the guy doing the treatment, that’s pretty hard to swallow,” he said.

Sure enough, urologists — the doctors who most often treat prostate cancer — promised to fight. The American Urological Association issued a statement saying that the recommendation “will ultimately do more harm than good.” Many urologists reacted angrily.

“All of us take extraordinary issue with both the methodology and conclusion of that report,” said Dr. Deepak Kapoor, chairman and chief executive of Integrated Medical Professionals, a group that includes the nation’s largest urology practice. “We will not allow patients to die, which is what will happen if this recommendation is accepted.” He and other urologists said that the P.S.A. test is just one part of an overall strategy that, in the hands of well-trained doctors, can help prevent death and other consequences of cancer.

Treating patients with prostate cancer is a highly profitable business in the United States, and much of the practice of urology is dedicated to this fight. If men no longer get screened routinely, urologists will see a steep decline in patient visits and income. But Dr. Kapoor rejected the notion that profit plays any role in his defense of screening.

“That I’m going to treat patients that don’t need therapy is morally repugnant,” he said.

But Dr. Otis Brawley, chief medical officer of the American Cancer Society, suggested that is what doctors like Dr. Kapoor are doing. “We in medicine need to look into our soul and we need to learn the truth,” he said. “If your income is dependent on you not understanding something, it is very easy not to understand something.”

 

It is easy to blame the support of the PSA test to greed. The accusers bear no responsibility. They just accuse and even might get away with it.

Why has the USPSTF ignored the 40% reduction in prostate cancer mortality in the USA since the commercialization of the PSA test?
Answer: Because they can get away with it by repeating time and time again that the reduction in mortality has been small...If you say it enough times it will stick as true.

Why if PSA testing in not effective, mortality from PCa has continued to increase in countries that have limited use of the test? Why is the USPSTF ignoring this data?
Answer: Because they can get away with it and more men die unnecessarily.

Why has the USPSTF been selective in the data used to issue the recommendation?
Answer: Because they can select what studies are good quality and which ones are not. They can get away with it because men are apathetic about their health issues.

I urge you all to write something against the recommendation. Don’t let them get away with it!

RalphV

Casey, the article you provided says, "Treating patients with prostate cancer is a highly profitable business in the United States, and much of the practice of urology is dedicated to this fight. If men no longer get screened routinely, urologists will see a steep decline in patient visits and income."

The obvious implication is that urologists want to continue this PSA testing, in spite of the USPSTF recommendations against it, because of a profit motive.....even though the recommendations put the PSA test in the category of unnecessary and potentially harmful medical practice.

When the article (and the USPSTF) suggest that it's the profit motive that is prompting urologists to deliberately support a testing procedure that the task force feels is harmful, I don't know how else to characterize that remark other than to say the article is accusing them of "greed."

John

Very well put together - I agree 100 % with your beliefs.

Bud

Casey,
You are over looking some important issues:
Treatments are better when applied to less disseminated disease. Without early detection by PSA testing even improved treatments would have not reduced PCa mortality by 40%. That is the case when current treatments are used in countries in which the use of PSA is not common and improved treatments are applied too late. PCa mortality there has not improved significantly and in some places continues to increase.

If most men diagnosed today have low-grade disease that would never impact their life expectancy even when not treated, then when they are over treated they would not impact the current PCa mortality rate. It is men that were destined to die of PCa, that when treated avoid dying of the disease that are impacting the mortality rate

I am of the 20 years ago generation of treated patients. Age at diagnosis was 71 and many of those men had such advanced disease that localized treatments were not applied. Even today as a rule most surgeons refrain from operating men older than 70. At that time many men were open up surgically, if lymph nodes were involved, they were closed back without removing the prostate gland.

You are free to not agree with the statement that men are apathetic about their health issues, but it is a reality in our country where there is not even one government department of men’s health issues and more than one for women’s health issues. I commend women for their advocacy and dedication, but I think that this reality is connected to our lack of advocacy on health issues.

In a previous post you quoted the following:

But Dr. Otis Brawley, chief medical officer of the American Cancer Society, suggested that is what doctors like Dr. Kapoor are doing. “We in medicine need to look into our soul and we need to learn the truth,” he said. “If your income is dependent on you not understanding something, it is very easy not to understand something.”

Isn’t that accusing Dr. Kapoor (a urologist) of greed? Are we the “appalled”in self-defense mode or is the “long overdue” sector who is trying to change reality?

RalphV

I have read and carefully considered both the USPSTF report as well as the many threads and posts on HW over the past couple of weeks that were referencing the subject.   Overall, while I personally disagree with many of the USPSTF conclusions, I think this report still has value in that it has brought the subject to the forefront.   It is hard to deny that PCa overtreatment exists just as it’s hard to deny that we have an out-of-control health care cost situation in the USA.   So, I think debate on the subject at the national level is healthy.   Likewise, I think Casey’s points that he has made on HW have been well thought out and have brought the debate home to a very involved audience on this site.   While I don’t always agree with Casey either, I think he has stood up to a barrage of criticism and, as usual, effectively defended his positions.   Unfortunately, some of the criticism of Casey has been disparaging.   For example, one moderator said to Casey, “Cancer is cancer. Repeat that. If you forget how to pronounce the words, there are a few folks who could help you with that”.   Given Casey’s personal/family history with cancer that is probably one of the ugliest things I have heard in my three years here and I would hope we could have this conversation with a little more decorum.   But I digress.   If the problems are overtreatment and out-of-control costs, it’s clear to me that the answer lies with either patients or doctors or insurance companies or the government.   It’s pretty obvious that patients and doctors have not been able to address this effectively, hence the government intervention via this report.   Personally, I don’t think the answer is to stop routine screening.   I have the same group think as most of us here, i.e. screening was what found my cancer, saved my life, helped my roses bloom and makes the sun come up.   I can’t help it…I just feel that way.     However, if I was King of Medicare and All Insurance Companies, I think I would institute a policy similar to one suggested by David (Purgatory) for which he was roundly criticized.   I would declare that treatment of early stage PCa, defined with specifics re G-score, number of cores, % of cores, etc. is NOT medically recommended except by AS.   Furthermore, I would restrict Medicare and insurance payments to PCa that is worse than these pre-determined guidelines.   Furthermore, I would declare than the various scans done in the name of baselining are NOT medically recommended unless G-score and PSA are at pre-determined levels.   Nor would I pay for such scans.   OK…there I said it.   Feel free to fire away.   Tudpock (Jim)

Well, there has been lots of comments by others about Casey’s posts in relation to the USPSTF draft recommendation release.    Actually, I think that despite multiple posts I’ve made, very few of my own personal viewpoints have been controversial…many of my posts have either been collateral impacts or situations where I brought other 3 rd party perspectives into the discussion; perspectives that can help those with open minds see holistically, but understandably are quickly blocked-out by those with closed minds. There has been 6 threads where the main topic has been the USPSTF release.   I did a quick “best of Casey” listing my own personal comments from each thread so that anyone who wants to disagree can be more specific.   You can say “I disagree with x.x and y.y”…or you can just say “I disagree with everything Casey says.” I didn’t think my own personal positions were that controversial…but as Tudpock said:   feel free to fire away.     Threads stating my own personal “opinion” and what those opinions were:   1.      10/7/2011 (the day of the USPSTF publication) “Screen nobody? Screen everybody? Or informed decision with your physician about PSA testing?” 1.1.    American Cancer Society PSA Testing Guidelines are looking more reasonable in light of today’s USPSTF draft guidance; ACS is not “anti-screening” 1.2.    My perspective: 1.2.1. men should be educated about PC and PSA testing by doctors before screening 1.2.2. over-detection is not the problem, over-treatment is; but when we educate men first, over-treatment will be reduced 1.2.3. aggressively treat those who need aggressive treatment, and don’t aggressively treat those who don’t need aggressive treatment 1.3.    PSA screening controversy has been distraction from progress in distinguishing between tumors needing, or not needing, treatment 1.4.    A call for civil and rational debate is appropriate to avoid mis-interpretation     2.      10/11/2011     advises%20 against%20 all%20 PSA%20 screening%20 in%20 healthy%20 men"> “USPSTF advises against all PSA screening in healthy men” 2.1.    Many people don’t have a clue about the extent of their own personal contribution to the nation’s healthcare bill 2.2.    The invalidity of the data used by USPSTF is not universally agreed upon 2.3.    Point out that Catalona’s comments come from a defensive & biased perspective     3.        10/12/2011    “**MUST READ** USPSTF Asking For Comments” 3.1.    “My crystal ball is indicating that” some significant good will come from all this; specifically that there will be increased recognition on lifestyle changes as a means of PC risk reduction 3.2.    More participation in “wellness” to “do their share” in improving healthcare system 3.3.    “I think that a lot of the controversy would go away if clinicians and patients stop equating detection with treatment.” 3.4.    Repeat:   “aggressively treat those that need aggressive treatment, and not aggressively treat those that don't need aggressive treatment”   4.      10/24/2011     “Addressing "the 'C' word" for low-risk PC” 4.1.    Suggestion from a “change management perspective” that “perhaps now is the time” (following on the heels of the USPSTF draft recommendation) to re-name very low-risk PC to something other than “cancer” 4.2.    “AS is not necessarily a forever decision...if a case progresses, they may elect to move to treatment, and studies have shown that the outcomes are essentially the same.” 4.3.    “ your Gleason score is what it is, and it remains that unless and until more updated information becomes available.   Nobody in their right mind would look at their G6 biopsy result and decide to cut, burn or poison themselves for the sole reason that they might be G7.   There’s a pretty fair chance they might also be G5 ” 4.4.    "For some cancers this fear [of “cancer” as a death sentence] is indeed warranted, but for most men with favorable-risk PC the situation is very different."   5.      10/20/2011    “Dr. Catalona condemns the USPSTF recommendations” 5.1.    Repeat:   Point out that Catalona’s comments come from a defensive & biased perspective 5.2.    “One should expect that those who make their living directly from the $30 billion industry that has grown up around the testing and treatment of PC to be passionate and vocal about their livelihood...especially the ‘father of PSA screening.’” 5.3.    ” It would be naive to completely overlook the economic self-interests of the $30 Billion industry which grew rapidly around PSA screening and treatment.” 5.4.    “I think Dr Catalona is an excellent surgeon...one just needs to also understand the perspective of where he is ‘coming from.’"  5.5.    “I thought that this group [HW]would be a much stonger advocate for preventing overtreatment.” 5.6.    Repeat:   “We need to spend our scarce resources for aggressively treating those that need aggressive treatment, and not aggressively treating those that don't need aggressive treatment...we will bankrupt our sons and daughters if we don't change.” 5.7.    Repeat:   “Unfortunately, many are clueless as to the real "cost" of overtreatment...they think (naively) only of their own personal out-of-pocket/deductable are their costs.  Newsflash:  Medicaid pays the vast majority of PC treatment (and therefore overtreatment) costs in this country...and we all are borrowing from our children to pay.” 5.8.    Repeat:   I support the ACS PSA screening guidelines, which I think is common sense approach 5.9.    The “USPSTF document, as I posted in another thread, states its recommendation against mass PSA screening (although it remains supportive of PSA testing for individuals after an informed decision, and supportive of PSA testing for diagnostic purposes).” 5.10. The USPSTF release “has helped raise awareness of the issue of severe complications and patient suffering from the overtreatment of indolent prostate cancers”   6.      10/26/2011      “"Screening Saved My Life" — a popular sentiment, but how true?” 6.1.    There are many “brothers overtreated for PC but emotionally convinced that their treatment was necessary and saved their lives.” 6.2.    “There is a school of thought   that says those who die of PC will do so regardless of treatment/non-treatment in about the same timeframe. ” 6.3.    “ there is very surprising little uproar here about the extent of overtreatment.   There appears to be very little concern about the next guys coming through the door…instead, we hear mostly about the defensive rationalizations essentially in support of overtreatment!   impart a little more “hard knocks” wisdom, but we get lots of “ you should do what I did ” suggestions for the new guys more than anything. ” 6.4.    “ If we can’t educate patients better, I don’t know how the doctors (who you’d be incredibly naïve not to understand have a financial stake in keeping the machine going) will step-up and start suddenly practicing conscious-based medicine. ” 6.5.    “ Nowadays, it is thought to be unethical to screen men without them being aware of the pros and cons of PSA testing, and in the fact an informed choice is shown to be related to better patient outcomes. ” 6.6.    “There is an (appropriate) uproar about any media generalizing that all PC is harmless.   All PC is NOT harmless , and it would be an ignorant and insulting implication to say that it is.   But a not insignificant portion of PC is harmless (perhaps to the tune of a million men in the last 20 years, according to a study funded by the Prostate Cancer Foundation).” 6.7.    Repeat:   “In fact, it is like two different diseases, but unfortunately it is all called the same name: “prostate cancer.”   Maybe if we called it something different…”    

Casey, Easy there, big guy.
I for one have been a fan of your intellectual postings since you arrived. I don't always agree with your viewpoints but I have no doubt that you have taken the time for the most part to think your posts through and delivered some great insight (and incite) for men to think about. And your work and attendance outside this board are also something that I admire.

Some of my favorite "debates" with you have resulted in some excellent points surfacing.

Keep 'em coming...

PS: I was kinda hoping to see your response to my post and the possible affect the USPSTF recommendation may have on prostate cancer research funding. I don't think people are seeing the bigger picture yet. I also think that Ralph's point is valid when he points out that to be effective, many treatment options have to be started earlier rather than later. Thus the fact that treatments have improved over the years is culmination of early diagnosis and treatment rather than the "wait till you have symptoms" approach that the USPSTF is recommending. We have no data to suggest that these "better therapies" will in fact be better when waiting too long to use them...

Tony

Tony, regarding your earlier posting, I haven't commented yet because I haven't fully digested the notion you raised about the possibility of research funding cuts. On the one hand, I don't think we want to (and you weren't suggesting that we) artificially inflate numbers with the intent of supporting more funding. On the other hand, there are clear research needs that we have. On the other hand, if we could seriously cut back the numbers overtreated for PC, there could possibly be much more money available to accomplish the research needed...in the US, it costs $5.8 million to test & treat all those necessary in order to save one life from PC.

There is another valuable point which Ralph has made recently which I have realized also deserved more visible support...and I haven't spoken up on it. While there is clearly many men sadly overtreated for PC, Ralph has pointed out that there are also many men grossly underserved by the current medical system in this country because they are under-insured or un-insured. They aren't having any "informed decision" opportunity at all because they can't afford to go to a doctor, and then they show up in emergency rooms (where we all pay anyhow) for advanced problems. Our current healthcare system sucks.



Clocknut, this group here at HW is a great and (mostly) supportive group...but it is also a very small segment of society with a set of common views. Sometimes it's hard to see the forest through the trees.

I didn't see anything new in the CNN link you provided.

Tudpock, I agree that there are bound to be plenty of cases where a gung-ho urologist has said "prostatectomy!". But to present a solution that appears to throw out the whole prostate cancer operator manual and says "stop, it's all rubbish!" is dangerous, and it's very confusing and misleading for men.

They (I can't bring myself to call them by name they have demonised urology so badly) are saying PSA testing is a waste of time. They are saying that intervention in prostate cancer is overall negative or at best neutral. The clear implications are as Clocknut said that the urology industry stands accused of greed and that all of us who have had surgery or radiation or HT have been down a wrong turn into the hands of urologists who have been found to be practising something which is not clearly beneficial.

How we (urologists and patients) are not supposed to feel either insulted or duped, respectively, because of these statements you can contemplate. As a professor of statistics once said to our class, "you can make statistics reveal almost anything you want them to". Just like almost every radio and TV station boasts that the new ratings show them to be number one.

Men, we need to be able to rise above this gobblydygook from a faceless bureaucracy and push for a coherent screening policy that empowers and informs men to front up and understand the second biggest cancer threat for men. If this report and recommendation contains anything it is a rallying call and a refocussing of how to best deploy expertise in preventing death from what is often a deadly disease.

Post Edited (KickintheButt) : 11/4/2011 12:13:20 PM (GMT-6)