|"Prostate Controversies" by Allen Weiss, MD, MBA, President & CEO|
December 15, 2013 - “We need better ways to screen and treat prostate cancer. Until we make these discoveries, and even once we do, men and their families will turn to trusted health care professionals to help them make informed health care decisions.”
This bottom line statement is the result of a comprehensive review of medical evidence conducted last year by the U. S. Preventative Services Task, of recent extensive clinical trials on prostate screening.
After careful study and even considering the controversy they anticipated, the task force recommended against prostate-specific antigen (PSA) based screening for prostate cancer—their thought being that the potential benefit does not outweigh the expected harms.
Dr. Richard Albin, the discoverer of PSA, stated in a 2010 New York Times editorial, “Screening men for prostate-specific antigen (PSA), the most commonly used tool for detecting prostate cancer, has become a "hugely expensive public health disaster."
The benefits of screening based on large clinical trials have shown that, at best, PSA screening may help 1 man in 1,000 avoid death from prostate cancer after at least 10 years from when first diagnosed. Most likely, the number helped by the test is even smaller.
Among the men who are not screened, about 5 out of every 1,000 men will still die from prostate cancer after 10 years of diagnosis. This translates to the fact that PSA screening for 1,000 men who might otherwise not be screened, four of five with a positive test will still die from prostate cancer after 10 years. This is even if they might have been screened. Therefore screening only helps one in 1,000.
There are problems with the accuracy of the test—not so much that the number reported is incorrect but that there are false-positive results, over diagnosis, and over treatment with known almost unavoidable complications.
- False-positive results—about 100 to 120 of every 1,000 men screened receive a false-positive result. Most positive tests are appropriately followed up with a biopsy, worry and anxiety. Biopsies, as all invasive procedures, may have complications.
- Over diagnosis—most prostate cancer is slow growing, indolent, and many remain without symptoms for life and do not require treatment.
- Over treatment—about 90% of men diagnosed with prostate cancer elect to have treatment. About 29 men per 1,000 will have erectile dysfunction, 18 per 1,000 will have urinary incontinence and there is a small risk of death, unfortunately present in any surgical procedure.
Treatment is also full of controversy as more and more patients, physicians, and insurers are looking for evidence based medicine as treatment options are considered. Standard radiation therapy currently is IMRT—intensity modulated radiation therapy—which uses a computer-guided X-ray approach to minimize damage to surrounding tissue and organs.
Proton beam therapy is a newer and markedly more expensive option available at a few dozen large academic institutions. Evidence-based medicine thus far has not shown any decrease in complications after one year of treatment and no difference in outcomes compared to the less expensive conventional treatment. A few insurance companies are now refusing to pay for the much more expensive modality. Medicare, the largest player in the market is still paying although reimbursement is falling as hospital billing costs for this modality are coming down. Medicare’s payments are somewhat proportional to the cost of producing a treatment. All this information is gleaned from an August Wall Street Journal article.
Nothing is straight forward anymore. Science progresses, the value equation (quality/cost = value) is still front and center even as our economy recovers. We still spend almost twice as much as other developed nations on healthcare; this has got to stop if we want to maintain our position as a leader in this globally-competitive world.
Stay tuned as the controversy remains unsettled … and unsettling.
Past Health Advice Articles
Dr. Allen Weiss is CEO & President of the NCH Healthcare System. He is board certified in Internal Medicine, Rheumatology and Geriatrics, and was in private practice in Naples, Florida from 1977 - 2000. Dr. Weiss is active in a variety of professional organizations and boards, and has been published in numerous medical journals, including the American Journal of Medicine and the Journal of Clinical Investigation.