Get your PSA checked, men

Here’s audio of an appearance on The Takeaway on public radio this morning about the American Cancer Society’s new prostate (PSA) screening guidelines, telling doctors to discuss the test and its implications first — the moral equivalent of the breast-cancer-screening shift of a few months ago. I disagree. As the n in a hundred whose cancer was caught by screening, I caution that the interest of the individual are not aligned with the interests of the aggregate — that is, it may not seem worth it to statisticians to save just one more life … unless that life is yours. For those coming in because of the show, my story is here.

  • Barbara Raab

    Hi Jeff,
    This is always a third-rail conversation to get into, especially with cancer survivors, but here goes: despite my own fears of all kinds of diseases and conditions, and the desire for every sort of screening that could detect them early, I disagree with you.

    I do agree that, from any one individual perspective, the interests of the individual are not aligned with the interests of the aggregate. However, in a world where health care is not free, and resources are not unlimited, doesn’t overall health policy have to be based on the interests of the aggregate? Any other model is not sustainable *for* the aggregate.

    This is not to suggest that any individual cannot or should not consume more screenings, procedures, etc., than are codified in official “recommendations” or “guidelines,” and I agree with you that each of us should have information on which to base our individual decisions.

    But isn’t it fair to say that – for example – the woman of statistically normal risk who nonetheless wants regular mammograms beginning at 35 to set her mind at ease, should bear (at least most of) the burden of that cost? I’m not suggesting she should not have those screenings if she wants them (I wanted them and got them), or that men should not have PSA tests on a regular basis, but shouldn’t the guidelines, the norms, be based on what is statistically most efficient in the aggregate, and anybody who wishes – for good or bad reasons – to go outside those guidelines, be asked to shoulder the financial responsibility?

    There are other grounds on which I could argue this point even further (i.e., is it really in the interests of the aggregate or even any one individual to have doctors, radiologists, etc., using their time to test and screen lower-percentage risk groups versus having the time to offer care to the truly sick?), but I’m curious about your response to the threshhold question posed here. Thanks.

    • http://www.buzzmachine.com Jeff Jarvis

      Do we at least agree that ignorance is not bliss, that trying to get people not to know just to save money does not serve them? It’s not so much about the cost of the test as the treatment. Of course, once I know I have cancer, I will want to deal with it and that’s quite rational until the day when science knows enough to determine which forms are riskier. Today, they dont.

      • Barbara Raab

        Oh yes, we agree that ignorance is not bliss. I propose maximum information, with guidelines that incorporate what we currently know, statistically, about what is optimal for the aggregate. I completely agree that I doctor should say to me, “Now, that’s for the population as a whole. It is true that some women who are screened at age 40 find evidence of X, and the treatment saves their lives. Your risk, based on what I know, is about average. Would you like to have a screening? If so, I will support you, but you should know that your insurance company probably will not pay for all of it,” or something like that. I do NOT think doctors should just say to people, like robots, “You are 45. No PSA for you. Next?”

    • Andy Freeman

      > I do agree that, from any one individual perspective, the interests of the individual are not aligned with the interests of the aggregate. However, in a world where health care is not free, and resources are not unlimited, doesn’t overall health policy have to be based on the interests of the aggregate?

      Nope.

      > Any other model is not sustainable *for* the aggregate.

      No again.

      First of all, the aggregate doesn’t exist in the sense that you and I do. It’s just a tool used to do analysis. However, that analysis is incomplete and can only tell us certain things.

      Health and health care is not uniformly valued. Look at the people around you for proof. People make different choices, and there’s nothing wrong with that.

      If someone decides “I want to live it up”, great. They get the fun, they get the costs. Similarly for someone else says “I’m going take it safe”.

      The problem comes from folks who want others to pay the costs (either for themselves or for someone else). Why should we take from those who played it safe to protect others from the consequences of said others’ decisions.

      It doesn’t matter whether Jarvis’ health care consumption is “sustainable by the aggregate” – it only matters if Jarvis’ health care is sustainable by him. As long as each person’s health care is sustainable by that person, the aggregate is sustainable.

      Note that “health care by aggregate” tends not to be sustainable because the aggregate will make unsustainable decisions, as the US deficit proves. (Countries with national healthcare aren’t any better off.)

      • Barbara Raab

        I don’t disagree. But these testing guidelines often dictate who pays for the choices that individuals make. I am simply arguing that the cost ought to be spread where the medicine is evidence-based. Beyond that, every Jarvis and Raab and Freeman ought to sustain his/her own choices. And there is NO hope for health care reform without that approach, IMHO. You can’t make health care universally accessible if there are no limits on aggregate spending; and I’m arguing that evidence ought to drive the establishment of those limits. I’m not sure you and I are really in disagreement here.

      • Andy Freeman

        > But these testing guidelines often dictate who pays for the choices that individuals make.

        You’ve got it backwards. Yes, organizations use guidelines, but they’re free to use different guidelines.

        > You can’t make health care universally accessible if there are no limits on aggregate spending;

        You’re making unnecessary assumptions and stuck on “aggregate”.

        Individuals have finite resources, albeit some more than others. Why should Jarvis be constrained by other people’s choices?

        > I’m arguing that evidence ought to drive the establishment of those limits. I’m not sure you and I are really in disagreement here.

        We are because you keep talking about “aggregate” and “limits”. Jarvis’ limits are his resources, not what someone thinks is appropriate for an “aggregate”, regardless of the basis for their opinion.

        Yes, one can compute statistics over the aggregate, but there’s no reason to think that such statistics are a guide for individuals. They’re derived, not driving.

  • Elizabeth O’Connor

    I just want to say how happy I am that there are people like you out there that are sharing their stories and are not afraid to talk about it in such detail. I’m confident your story will reach many and will probably save lives. Bravo!

  • http://editorandpublisher.com Mark Fitzgerald

    I guess I’m like you, Jeff, I can’t even imagine why this is a debate. My prostate cancer was undetectable by the digital rectal exam, even after a biopsy when urologists knew I had cancer. If I hadn’t taken PSA tests routinely, I would have cancer now, and it could have spread well beyond my prostate. This might be a good time to explode this constant myth about how supposedly “slow” prostate cancer is. I was fortunate to be diagnosed early with localized cancer. But it was also, like many prostate cancers, near a nerve cluster statistically linked with the spread of cancer to other organs. As my surgeon at Northwestern Memorial in Chicago Dr. William Catalona put it in an article the other day, “watchful waiting is often wishful waiting.” Regular PSAs can show if some cancer is brewing even if the bottom line number stays below the magic 4. When my PSA spiked in the early summer of 2008, a look back showed it had been very slowly creeping up for several years.
    Sure treatment can be tough. Catheters are a literal pain. Incontinence is awful. But it doesn’t last long, and compared to the chemo my wife went through more than 20 years ago, I figured I got off easy. In any case, it’s way preferable to death.

    Jeff is right: men, check your PSA.

  • http://www.causewired.com Tom W.

    Jeff –
    Thanks for this. My elderly father has late-stage prostate cancer, and it’s a dreadful disease. I’m a believer than screening can save many lives.

    That said, it’s far from a panacea, as any doctor will tell you. In the case of my dad, he was checked regularly at least twice a year from the age of 60 on and it still crept up and got him. His doctor said that with his type of cancer, no screening in the world would have prevented this.

    I’ve learned in the course of this that everybody’s cancer is indeed different. People assume with breast and prostate cancer especially that the “victim didn’t check” and they shake their heads. Sadly, not so at all.

    Nonetheless, get screened.

    TW

  • http://www.earthlab.net Brandon Keim

    From Emily Walker’s MedPage story:

    ===
    “We need a better test than PSA,” said Brawley, who is a vocal critic of over-reliance on PSA screenings and overtreatment of prostate cancer. “PSA is a lousy test. It misses as many cancers as it finds.” [....]

    Of the four studies to which Brawley is referring, two found a higher mortality rate among men who were screened for prostate cancer; one — a large U.S. study — found no difference in mortality rates among those screened and those not screened; and the fourth, a large European study, found that men who were screened were more likely to survive than those who weren’t (P=0.04).
    ===

    I’m not an expert on PSA risk, but it seems to me that there’s a genuine problem here. It’s not just, “We could save more lives but that costs money” — it’s, “Maybe we’re not doing a very good job of saving lives.”

    • Barbara Raab

      If I could just jump in here … this is part of what I was trying to get at; the goal is to do the BEST screening, the BEST care, the BEST job of saving lives — for the most people. And that’s why looking at how we’re doing in the aggregate, and allocating resources based on what the SCIENCE and STATISTICS tell us in the aggregate — while not necessarily comforting for any given individual — is what we need to be doing. If we can look beyond our own individual situations, we get to a place where health care is the best it can be in the aggregate. As Brandon Keim says, maybe each individual is comforted by getting to have lots of tests, but “we’re not doing a very good job of saving lives.” THAT is where we, in the aggregate, need to put our energies.

  • http://andforeveryoung.blogspot.com/ Ted St. Godard

    Interesting discussion. Please see “Should I be Tested for Cancer?” 2004, by HG Welch. We all live in a world where we’re convinced “early detection” is better, but Welch argues – convincingly – that we really have no way of knowing for sure that this is the case. Indeed it is probable that a great many of the cancers “discovered” incidentally (ie via screening in asymptomatic patients), and “treated” would not have become problematic at all, in which case, sorry, ignorance might have been better. We don’t want to bury our collective heads in the sand, but neither do we want to think it’s absolutely in our individual (to say nothing of aggregate) best interests to be constantly on guard. What’s next, monthly whole-body MRIs?

  • http://www.ovative.com Kim Garretson

    Jeff & Barbara Raab:

    Thank you for your lively discussion. I’m much more on Jeff’s side, for personal reasons. I had no knowledge of family history of PCA on my mother’s side because I was estranged from that side of the family, and my doctor never suggested the PSA test for three years of digital exams only when I complained of frequent urination. When he finally did the test, I was 51 and my PSA was 159 & I was in big trouble. It’s now 7 years since surgery and I have still have PCA but have managed it fairly well. So, my ignorance and guy’s facade of invincibility & the doc’s failure to even do the minimum in informing me of the suggested options for me to consider almost killed me.

    Now, to Barbara’s arguments about the aggregate needing to drive reasonable healthcare guidelines and costs. If men at the age of risk in particular, and healthcare consumers as a whole, are going to be swung to this argument, then the healthcare and health insurance industry need to transparently publish the actuarial tables behind these arguments and guidelines. I have never seen a chart for how much PSA tests cost insurers or individuals (I’ve heard about $90), how much biopsies cost (along with the percentages of false positives), how much treatments cost (drugs and/or surgeries), all layered over the number of men diagnosed a year and the number of deaths a year, including the age of diagnoses, ethnicity, etc., etc. If the health insurance industry would like to inform me and public with all this info, including its profits (which I understand it needs) in the aggregate of men tested, diagnosed, treated and those who die, then perhaps I would move a bit more in the direction of your argument Barbara.

    Again, thanks for letting me weigh in.

    • Barbara Raab

      Kim,
      I don’t disagree with you – as you can see in my response to Jeff’s query about whether I am in favor of transparency and information. But by the same token, even when reputable journals publish high quality research about the relative benefits and costs of routine screenings (see, e.g., the recent study about the efficacy of mammograms for the population as a whole under 50, versus the downsides of false positives), Americans revolt. We don’t seem to want to let science and facts drive our decisions, in many cases. Perhaps there was a time when the facts suggested all women should have annual mammograms starting at 40; now, however, the research shows otherwise, and women don’t want to let go of the “40” guideline, even though the science suggests it is not only unnecessarily expensive in the aggregate, but actually counterproductive in the aggreegate from a public health perspective. Imagine if we didn’t want to believe germ theory. That may sound ridiculous, but there was a time when germ theory replaced whatever came before it, and can you imagine if the public simply decided it liked what had been disproven instead? My point is, I agree with you that information is a pre-requisite to good decision-making, but I think there also needs to be a greater aggregate willingness to act on facts and not just fear. Fear is understandable but it should not trump facts when it comes to health policy or even individual health choices.

  • Nicole

    My father, who is a prostate cancer survivor and I had this conversation yesterday. A screening is a screening and should be routine. The AFP quad screen for birth defects during pregnancy is notorious for false positives but no one is suggesting that it not be offered because the follow up AFTER a screen determines the course of action and provides the family with information that allows them to prepare for the outcome or make choices. The PSA should be treated the same way.

  • Steve

    Barbara: You are absolutely right. At some point, to not believe germ theory was the ultimate ‘head in sand” stance. And then at some later point, to not believe it was suicidal.

    But it is a poor (I’d say specious, but I hate incivility) comparison to suggest that those rejecting germ theory are similar to those who have serious problems with public health policy derived, however rigorously, from large populations.

    Germ theory was a hypothesized and then proven direct causal relationship. Not every germ infected every victim, but the general causal relationship is solid, is established.

    The policy about mammograms, and other suggestions about over testing of PSA, are also soundly derived. But they derived from large populations and yield probability data and not “A” causes “B” data. Mammograms at certain ages may yield false positives and they may lead to unnecessary and worry-inducing tests. But the tests, correctly administered, do not cause pathology. They either find it or don’t find it and the large scale data is used by some to deduce the point when they believe the cost of finding it in a large population is too great. Reasonable people can argue about when the cost of testing between 40 and 50 is or is not too great.

    But no reasonable person can argue that, as a general proposition, germs cause illness.

    You are trying to turn a nuanced, complicated moral and ethical cost-=benefit calculation about testing into an unassailable causal relationship.

  • Barbara Raab

    Perhaps i am not being sufficiently skeptical about the current science, derived, as you say, from large populations. That’s a fair criticism. But at the end of the day, isn’t the real question, no matter how we get there, whether each and every person has the unassailable right to the best possible detection and care, no matter the cost? Isn’t that what we — and the nation — are really grappling with?

  • Andy Freeman

    > But at the end of the day, isn’t the real question, no matter how we get there, whether each and every person has the unassailable right to the best possible detection and care, no matter the cost?

    No again. Healthcare is not special. You wouldn’t say that that every person has the unassailable right to the best shoes or food.

    Of course, if Barbara wants to subsidize my healthcare, I’ll happily take her money. However, I’m not interested in returning the favor.

  • Barbara Raab

    But Andy, that’s the thing: Americans DO think healthcare is special; that every person has the unassailable right to the best shoes or food. That’s why nobody wants Jeff’s headline to be: Get Your PSA Checked, Men; And Pay The Bill.

    • Andy Freeman

      > Americans DO think healthcare is special; that every person has the unassailable right to the best shoes or food.

      Oh really?

      Where do you see evidence that Americans are willing to spend unlimited amounts of money on other people’s healthcare?

      Where do you see evidence that Americans are willing to sacrifice their own healthcare for someone else? (Unions sure aren’t – that’s why they got the exemptions from the “cadillac tax”.)

      The most that you can say is that Americans are willing to provide a base level of care for folks in certain circumstances, which is a very different thing.

      • Barbara Raab

        What I meant was, Americans as a whole seem to believe they (we) are entitled to the best possible health care in unlimited quantities, and that “someone” should pay for it. These same people do not believe we’re entitled to the best shoes or food in unlimited quantities, but tell the truth about the fact that health care might be “rationed,” and Americans freak. I’m not saying Americans are willing to pay for other people’s health care; but they’re not willing to accept less than the best/the most for themselves and their loved ones. Most view anything less as a moral outrage. But best/most is not a sustainable model, at least not as it’s currently constituted. That’s why we’re at this point. System is falling in on itself.

  • Barbara Raab

    From an op-ed in this morning’s New York Times by Richard J. Ablin, who “discovered” PSA:

    “Testing should absolutely not be deployed to screen the entire population of men over the age of 50, the outcome pushed by those who stand to profit. I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster. The medical community must confront reality and stop the inappropriate use of P.S.A. screening. Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments.”

    http://www.nytimes.com/2010/03/10/opinion/10Ablin.html?ref=todayspaper

  • Steve

    Freem,an: No again. Healthcare is not special. You wouldn’t say that that every person has the unassailable right to the best shoes or food.

    Of course, if Barbara wants to subsidize my healthcare, I’ll happily take her money. However, I’m not interested in returning the favor.

    ____________________________________________________

    Damn, havent heard stuff like this since some of the lesser lights in my high school class dicovered Ayn Rand….But I do respect the consistency of kool-aid drinking libertarians…

    Just Curious:

    If we were in the ocean, post shipping-accident, would you at least TRY to help me before you saved yourself, if that help to me slightly reduced your own chance of survival?

    • Steve

      heaklth care IS different:

      Bad shoes = foot problems

      Bad food= stomach aches

      Bad health care = ?

  • cm

    More cancer awareness:

    http://www.london-sydney.com/

    Man are those guys going to have their prostates massaged!