Breaking News: The Downfall of the PSA

May 23, 2012

The United States Preventive Services Task Force stands their ground in this week’s Annals of Internal Medicine and recommends against the routine use of the PSA as a screening tool for prostate cancer. This Class D recommendation is grounded in data that suggests a “very small” mortality benefit at the risk of significant over-diagnosis and unnecessary treatment. The PSA should still be used to follow response to treatment in those already diagnosed with prostate cancer. This recommendation has already set off a media frenzy and we’re sure that we have not yet heard the last word on this extremely controversial topic.

http://www.annals.org/content/early/2012/05/21/0003-4819-157-2-201207170-00459?aimhp

3 Responses to Breaking News: The Downfall of the PSA

  1. ephraim mandel on May 23, 2012 at 9:49 pm

    Basically this is a politically based economic decision not a medical or healthcare decision, probably directly influenced by the Obama Administration in its quest to reduce healthcare costs. The physicians behind the decision are either ardent supporters of Obama, or attempting to curry favor with the administration so that they might reap personal benefit in either government (job) appointments or direct funding for their personal projects or institutions. This decision is so clearly at variance with the maintenance of the health and well being of the general male population, one must shirk in shame that American physicians would lend credence to such a blatant misuse of the confidence placed in them.

  2. Peter on May 24, 2012 at 7:33 am

    Ephraim,

    In relation to your above post, you claim that the recommendation was made to a) reduce healthcare costs and b) to curry favour with the administration. You then claim that this recommendation is to the detriment of the general male populations health.

    It is quite clear to all involved that there are benefits and disadvantages to the routine screening of asymptomatic males. The benefit being; to detect Prostate cancer earlier than would be detected otherwise, leading to a reduced mortality and reduced morbidity. However, the disadvantages of regular routine screening PSA for otherwise healthy men is that there will be false negatives and false positives (as with any screening program). Namely, that there will be people who do have prostate cancer despite having a normal PSA, who will be falsely reassured, and that there will be people who do not have prostate cancer, but who have a high PSA for other reasons.

    The data does not show that PSA screening saves significant lives. In fact, the regular routine screening of PSA will only save 1 life for every 1410 men screened. Although this would appear to be an expensive, if worthwhile cause, in reducing death from prostate cancer; there are many more factors to consider. The morbidity from prostate investigation and treatment is high; TRUS is an invasive procedure commonly done as the next investigation after an elevated PSA. (Having done a Full medical history and examination) This is a set of random biopsies into the prostate gland, and can cause an infection from the rectum as the needle enters the prostate gland (although rare).

    However, the main complications from PSA screening is the unnecessary morbidity associated with surgery from prostate cancer. Regular screening PSA increases the rate of surgery on men, a lot of whom would never have had any symptoms from their prostate cancer, and would have died from other causes. In fact, 10% of men die with prostate cancer. (Not from it). This leads to an awfully large amount of people having surgery that is probably unnecessary, and associated with high rates of erectile dysfunction, impotence, incontinence, some of which may be permanent.

    So screening really doesn’t save that many lives (48 prostate cancers need to be detected during the asymptomatic screening phase, rather than waiting until symptoms appear and then to investigate, to save 1 life from prostate cancer), and the investigations and treatment associated with a high PSA is at a very high rate of complications. It is a descision that is aimed at increasing the health and well being of the general male population.

    So essentially, ephraim, it is more complicated than a Physician-Obama scam to save healthcare costs, for example the debate over the effectiveness is not just done in the USA, but also in the UK and in the Republic of Ireland, as well as most of the non-english speaking countries of Europe.

    Check out the evidence, (which came from Europe, which is not currently under Obama control) http://www.nejm.org/doi/full/10.1056/NEJMoa0810084

  3. ephraim mandel on May 29, 2012 at 5:36 am

    I went to medical school in England, I’m familiar with British medical care. Do you realize that Guaiac stool tests are also not done routinely during a physical exam in NHS facilities? When I questioned why they are not done, since in the U.S. it is a routine screening procedure, I was referred to articles (analagous to the prostate articles you cite above)demonstrating the clinical futility of the test. Of course, under their breath, other physicians told me this an economic cost cutting measure. Is this the level of medicine we should aspire to in the U.S.? Cut the mammograms, cut the PSA’s, cut the Guaiac stool tests except of course for those who can privately afford to subscribe to private insurance plans which will include such tests, or pay out of pocket. And of course this clinical mentality extends to the larger issues such as lung transplants for patients with chronic progressive diseases like sarcoidosis; in England steroids until you expire, in the U.S. you are placed on a transplant roster. Politics and economics, with conveniently supportive studies, never the contrary studies that might hike the national medical budget.

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