Human Exceptionalism

Abandoning Men to Undetected Prostate Cancer

The march of cost containment continues, undoing decades of advice that we be screened for cancers in order to catch it earlier. First, it was a recommendation that women under 50 not be provided mammograms.  Now, it is a recommendation that insurance not cover men receiving the PSA blood test, which can detect prostate cancer long before symptoms appear.  From the NYT story:

Healthy men should no longer receive a P.S.A. blood test to screen for prostate cancer because the test does not save lives over all and often leads to more tests and treatments that needlessly cause pain, impotence and incontinence in many, a key government health panel has decided. “Unfortunately, the evidence now shows that this test does not save men’s lives,” said Dr. Virginia Moyer, a professor of pediatrics at Baylor College of Medicine and chairwoman of the task force. “This test cannot tell the difference between cancers that will and will not affect a man during his natural lifetime. We need to find one that does.”

Are you kidding me?  Of course it saves some men’s lives!  Indeed, I know middle aged men who had no symptoms, tested positive on the PSA test, and had their cancer discovered sooner rather than later.

The committee understands this, but believes that false positives and sometimes unnecessary onerous treatments, which sometimes lead to death, make the benefit not worth the risks–or the cost.  But that means abandoning some men to not having their cancers caught early because, in essence, it means no prostate screening at all:

“We’re disappointed,” said Thomas Kirk, of Us TOO, the nation’s largest advocacy group for prostate cancer survivors. “The bottom line is that this is the best test we have, and the answer can’t be, ‘Don’t get tested.’ ” But that is exactly what the task force is recommending. There is no evidence that a digital rectal exam or ultrasound are effective, either. “There are no reliable signs or symptoms of prostate cancer,” said Dr. Timothy J. Wilt, a member of the task force and a professor of medicine at the University of Minnesota. Frequency and urgency of urinating are poor indicators of disease, since the cause is often benign.

So, we should just wait until it may be too late to effectively treat the prostate cancer?  That’s a true Sword of Damocles.

I certainly understand the idea of recommending that older men not receive the test, because it grows slowly in older men. But that is not true in younger men, a time when prostate cancer can grow fast and be very lethal.  I am not alone in this concern:

Dr. Eric Klein of the Cleveland Clinic, an expert in prostate cancer, said he disagreed with the task force’s recommendations. Citing the European trial, he said “I think there’s a substantial amount of evidence from randomized clinical trials that show that among younger men, under 65, screening saves lives.”

This is our future. The bean counters will sacrifice the trees in the name of managing the supposedly evidence-based forest.

But it seems to me that the right approach is to disclose the very real problem of false positives. and let the men decide whether the potential benefit is worth the potential risks.  That treats patients like people, not cogs in a faceless bureaucratic system.

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