Wednesday, May 23, 2012

Ongoing PSA Debate

The current debate over PSA levels, testing and care continues. The NY Times has two articles yesterday on the Task Force Report.

Let me comment.

First the title was New Data on Harms of Prostate Cancer Screening.  The article was written by a woman, and yes that does mean something, but the title is basically false. The screening itself does de minimis harm unless there is something done improperly. Even saturation biopsy, 20 or more cores, can be performed in a properly prepped person with de minimis morbidity. Yes there are a few infections, and yes there is hematuria, and yes there is some minor nerve damage and discomfort,  but the alternative is rather terrifying. Colonoscopies have similar issues plus perforation of the colon. Is morbidity present, yes, to an overwhelming degree, in my opinion and experience, not really.

But one should read carefully the next to last paragraph:

xxxxx said that some men might look at the data on risks and benefits and decide that they still want to be tested, and nothing in the recommendations would prevent that. He also noted that federal legislation passed in the 1990s requires Medicare to cover the cost of P.S.A. testing, and that law will remain in effect unless Congress overturns it. Many insurance companies follow the lead of Medicare when it comes to reimbursement for health coverage.

 And the law will remain in effect unless Congress overturns it. Well, is that not what the Task Force is recommending. Let me remind the reader:

1. The Task Force is mainly concerned about the morbidity resulting from biopsies. That should be a decision made between the patient and their, in this case his, physician. Informed consent. It is not in the authority realm of the Task Force to tell me what discomfort level I should tolerate. If so then most likely no one would ever go to a Dentist as a child. However some discomfort to detect and remedy a PCa is much better than death from it.

2. It is true as we have argued that PCa comes in all shapes and sizes. And further as we have repeatedly reported and written on, PCa types are not yet identifiable. Does one have an indolent or aggressive form? In addition is there a cancer stem cell here we should try and find, perhaps. But we cannot and should not assume that since some are indolent we treat all people the same. Why not treat all women with breast lesions as DIC only, I rather not think so.

In the same edition of the Times there is a long discussion regarding preventive care. They state:

Could health care costs be reined in by improving access to preventive care? It’s an idea that appeals to policy makers and many public health experts, but the evidence for it is surprisingly hard to pin down. 

Is this not the same issue?