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Las Vegas article on the PSA controversy...

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Posted 8/20/2012 3:09 PM (GMT 0)
This is a piece that was done over the last couple weeks here in Las Vegas. Just a few viewpoints, including my own...

www.lvrj.com/health/prostate-cancer-test-ignites-controversy-166718816.html

Tony
Posted 8/20/2012 3:21 PM (GMT 0)
My comments in the article are in the same frame of mind Oscar Wilde must have used when he said "The only thing worse than being talked about is not being talked about."

Meaning that bad press is better than no press. The screening controversy in it's own strange way has helped educate men about testing and over treatment. But of course it can't stop there. You need to balance the logic with the other side of the controversy ~ that without screening the odds of dying from PCa are increased in the general population if all forms of screening are abandoned.

Tony
Posted 8/20/2012 3:47 PM (GMT 0)

This whole controversy reminds me of the saying that you go to war with the army you have.  It may not be the army you would LIKE to have, but we have to live in the real world.

So, understanding the limitations, you do the best you can with the tools available.  It's when you fail to understand those limitations that you get into trouble. 

Other than that, everything I can think of to say about the subject has probably been said on the forum, and people have their opinions set, I think.  You're right, though, Tony.  If all this "controversy" leads men to seek more and better information regarding the test and subsequent treatments, that's a good thing.

Posted 8/20/2012 3:58 PM (GMT 0)
Author sure jumbles whether to screen, whether to biopsy, whether to treat in this article. All three have their own criteria and trade offs. Press really isn't serving people well with this stuff.
Posted 8/20/2012 4:18 PM (GMT 0)
Bill,
I thought Paul actually did a nice job and the tone of "jumbling" things up comes from the USPSTF, the American Cancer Society, and the current state of prostate cancer screening matters, including doctors that were too quick to treat. It started with the ACS medical director saying he thought that PSA screening should end and that he himself will never be screened, and I think the USPSTF started running with it. I know some that will disagree with me on this but I think that when the top dog at the top cancer authority make such statements ~ the press is not responsible for the backlash just for reporting it. I agree with the ACS position that better education is needed as I said in the article. But if they are continuing to refuse to admit that there is indeed a life saving benefit to catching the disease early, then I will take an opposing viewpoint.

I have seen enough people die of this disease and they have always been diagnosed when the disease had progressed beyond the prostate when the diagnosis occurred. In my more than five years at this I have never met a man treated with local disease die from it.

Tony
Posted 8/20/2012 4:28 PM (GMT 0)

TC-LasVegas said...

...
I have seen enough people die of this disease and they have always been diagnosed when the disease had progressed beyond the prostate when the diagnosis occurred. In my more than five years at this I have never met a man treated with local disease die from it.
...

The question is, would they have died without that treatment? From the article:
Though three-quarters of men older than 80 and a third of men between ages 40 and 60 have cancer cells in their prostate, data show that men have just a 2.8 percent lifetime risk of dying from the disease.
Posted 8/20/2012 4:29 PM (GMT 0)
in my mind there is no controversy.  i know what i'm going to do.

ed

Posted 8/20/2012 4:36 PM (GMT 0)
onthefence,
I am certain that treatment does in fact save lives. The reason for the 40% decrease in PCa specific mortality is treatment ~ not diagnosis. To what percentage it's due to local therapies or improved advanced therapies is my only question.

Tony
Posted 8/20/2012 6:37 PM (GMT 0)
I'm with F8(Ed) on this subject. That's my story, and I will stick to it.

David
Posted 8/20/2012 6:58 PM (GMT 0)

TC-LasVegas said...
onthefence,
I am certain that treatment does in fact save lives. The reason for the 40% decrease in PCa specific mortality is treatment ~ not diagnosis. To what percentage it's due to local therapies or improved advanced therapies is my only question.

Tony

Tony,
Don't you think this improvement (reduced PCa mortality) is associated to early detection (through PSA testing) of disease stages and improved treatment modalities?

In countries in which the use of PSA testing is not as frequent as it is here in the US, even with improved treatment modalities, the PCa mortality reduction has not been as high. This gives credit to early stage detection of the disease in which treatments are able to reduce mortality effectively.

RalphV
Posted 8/20/2012 7:06 PM (GMT 0)
Ralph,
I don't think the drop in mortality is solely due to PSA screening. It's a large part of it, but i think other factors are involved such as improved therapies ~ which have less chance of being effective if the cancer isn't found early. Thus my comment is that I don't know what percentage of the 40% drop is due to screening and what percentage of the 40% drop is due to improved therapies is an accurate statement. Because I don't know and there is no data strong enough to say.

I am pro screening and not against it. But as I stated in the article ~ more attention due to the controversy hopefully leads to better educated and more aware men making decisions after they are screened...

Tony
Posted 8/20/2012 10:22 PM (GMT 0)
Tony,
I know that you support screening. I did not say that screening alone accounts for the reduction in PCa mortality in the US. My point is/was that in the absence of early detection by PSA testing, all the improvements in treatments are less effective as shown in countries in which the use of PSA testing is low. Unfortunately, our efforts in promoting awareness have been drowned by the noise created by the USPSTF. To suppress over diagnosis and over treatment they condemn men to potentially advanced disease diagnoses...

RalphV
Posted 8/21/2012 12:52 AM (GMT 0)
onthefence,
The USPSTF recommendation assumes a one size fits all approach to prostate cancer and prostate cancer screening. That I do not subscribe to. I am that patient that no one on that panel considers by using a blanket statement to cease ALL PCa screening viw the PSA test.

To be clear, overdiagnosis indicates the inability of men as a population to handle a diagnosis psychologically. I don't think that's try. I think men can be educated to understand that PCa does niot always have to be treated. Over-treatment is another story. Many men have been over treated.

But I was not. So to me the USPSTF point of view is, while not entirely inappropriate, it is as bad as the concern about screening was in the first place...

Tony
Posted 8/21/2012 4:43 PM (GMT 0)
The controversy isn't medical. There is no doubt in my mind that the PSA test leads to earlier detection and the opportunity to cure. Decreased death rates in the PSA era, etc.

The controversy is financial. As the provisions of the new health care law become known, it turns out that insurers are required to pay for tests recommended by the USPSTF. By taking the PSA test off that list, there should be big cost savings and therefore lower costs to the government. Not to mention, the lower costs due to less medical intervention for undiagnosed disease.

This isn't a political opinion, just a statement of fact.
Posted 8/21/2012 5:46 PM (GMT 0)
Frack me,
Not all you say is the way I hear and understand things. The USPSTF is not tied to mandatory compliance in the AHA in any way. In fact they are a team that defines what NOT to do as opposed to setting requirements for cancer screening. See linked description:

www.ahrq.gov/clinic/uspstfix.htm

The USPSTF is a group of medical volunteers serving as a panel to review clinician methods to evaluate the efficacy of procedure and practice. They make recommendations only and clinicians are in no way required to follow their recommendations. It is possible that some carriers do use the recommendations to outline what they cover and what they do not cover, however that is the decision in the private sector and not required by law for compliance to USPSTF recommendations. Their is supposedly no tie to the financials of disease or prevention and that is a requirement by law in the formation of the USPSTF in 1984.

Tony
Posted 8/21/2012 5:54 PM (GMT 0)
FrackMe,

You said:

As the provisions of the new health care law become known, it turns out that insurers are required to pay for tests recommended by the USPSTF. By taking the PSA test off that list, there should be big cost savings and therefore lower costs to the government.

I realize that insurers may see new costs, but the majority of men in the under-65 age group would be part of private-employer health plans. I'm not seeing a lower cost to the government in not doing a test under a private plan I pay dearly for. Might cost me more.

Not to mention, the lower costs due to less medical intervention for undiagnosed disease.

I found a completely different opinion from my (big national) insurance company. I asked why some tests in my PCa journey were so easily paid (while I was nagging them about my Cialis). Their response was that it was much cheaper to pay for surgery or RT than it would be to pay ongoing chemo and then end of life care for someone who went to stage 4. If you died of something else first, the statement makes more sense, but ...

Posted 8/21/2012 6:07 PM (GMT 0)
Well said 142,
Most carriers go beyond the USPSTF recommendations as we sit today, and that will likely be a selling point to any carrier trying to sell group plans. none of them will want to sell you the bare minimum as that leaves only cost to determine if they are a practical decision for insurance.

As it sits today the Affordable Healthcare Act in fact outlines coverage for PSA screening in men beginning at age 50 ~ which totally goes against the USPSTF Grade D recommendation.

There is a stipulation in the AHA that Grade A and Grade B recommendations must be a part of coverage. But there is no stipulation that C,D, and E not be covered. It's important to note that most carriers, and Medicaid and Medicare, do in fact cover PSA screening, and the latter two is by law.

Tony
Posted 8/21/2012 7:09 PM (GMT 0)
142,

The government is going to pay for/subsidize private insurance for the uninsured. These policies will be bought in the private market, through the exchanges. Eliminating the cost of testing and intervention will lower the costs of these insurers, who are essentially limited to cost plus under the new law.

Plus, the way the new law works, with small penalties for not having insurance and the right to buy insurance without pre-existing limitations, many people will forego coverage until they get sick. The end game will be single payer, with the government bearing all of the expenses.
Posted 8/21/2012 7:32 PM (GMT 0)
Ralf, your final reply above to Tony, was very well said, and mirrors my opinion on the subject. You just articulated better than I could have. I understand where you are coming from. Hope you are doing well, with all that blasted heat out your way.

David in SC
Posted 8/21/2012 7:42 PM (GMT 0)
Isn't moving people into insurance of any sort and therefore some sort of managed care going to be a lesser cost than swamping emergency rooms, and effectively raising costs for everyone else anyway?

I just don't see how this will raise what I spend. Moving money from property and sales taxes at the county level to cover our "public" hospital to a federal bucket seems like a shell game, but it is the same nickel. And yes, I know taxes never seem to go away, but at least right now the line items that go into my county taxes are clear. If the cost of the hospital goes down, the taxes go down.

We are already paying.

Posted 8/21/2012 7:48 PM (GMT 0)
Without a political conversation...

The USPSTF is not controlled by the Affordable Care Act. That I can state for sure is fact. To date I still don't think anyone with authority knows what we have yet and it's too early to say how it will affect PSA screening which is mandated in the act...

I am certain that many parts of the act still conflict with law and with itself, but this isn't the place for it to be debated...

Tony
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