American College of Physicians: Internal Medicine — Doctors for Adults ®

Friday, June 22, 2012

Why I won't have a PSA test when I turn 50

Generations of patients and doctors have been steeped in the myth that any kind of cancer should be found as soon as possible and when found, removed. The image of a gray-haired doctor on television telling the frightened patient "If only we had caught it sooner ..." has convinced us all that cancer must be diagnosed ASAP.

But it turns out that diagnosing prostate cancer sooner hurts more than it helps. For the last two decades many men over 50 have been regularly screened for prostate cancer with a blood test called PSA (prostate specific antigen) despite the fact that there was never any evidence that this test saves lives.

Last October the U.S. Preventive Services Task Force (USPSTF) reviewed the available studies about screening for prostate cancer. Their preliminary recommendation was against routine screening of men at any age for prostate cancer. (I wrote about their recommendations at the time.) The USPSTF, after considering public responses to their recommendations released their final recommendations, which are essentially unchanged. The USPSTF recommends against PSA screening for prostate cancer as it concludes that the benefits from screening are small or nonexistent and do not exceed the known harms of screening.

How is that possible? There is no question that many more prostate cancers have been diagnosed since the advent of PSA testing and also no question that the cancers diagnosed are at a much earlier stage than those found before PSA testing was routine. How can diagnosing prostate cancer more frequently and earlier not help?

To understand that we have to understand that prostate cancer is very common but rarely harmful. Prostate cancer increases in incidence with age, and grows very slowly. Prostate cancer frequently takes a decade or longer before it causes patients any harm. So many men with prostate cancer never develop any symptoms from it and die from some other cause at a ripe old age. Unfortunately, some men develop aggressive metastatic prostate cancer which cuts their life short, but we have no accurate way to distinguish which prostate cancer will remain indolent and which will be aggressive.

A consequence of this slow-growing but very common cancer that afflicts older men is that it's very hard to show that early detection and early treatment actually helps anyone. The studies reviewed by the USPSTF showed that the life-saving benefit of PSA screening is either nonexistent or very small.

If 1,000 men are screened for a decade with PSA testing, this will lead (many years later) to between zero and one life saved from prostate cancer. But much harm will befall those thousand men because of the testing. 150 to 200 of them will undergo prostate biopsies because of an abnormal PSA. One third of the men having biopsies will experience a significant adverse symptom as a complication of their biopsy, and one or two will require hospitalization because of a biopsy complication.

Many of these biopsies will turn out negative (because PSAs are so inaccurate) but some others will diagnose prostate cancer. Those patients diagnosed with prostate cancer will undergo treatment, frequently surgery, radiation, or both. Surgical complications will cause one of the men to develop a dangerous blood clot and two of the men to have heart attacks. Forty of the men will become impotent or incontinent because of their radiation or surgery. That's a lot of harm for very little, very uncertain benefit.

The specialists who (presumably with the best of intentions) have been making a living causing all this harm were indignant. The American Urological Association was "outraged", but perhaps their outrage will lessen when they ponder how much their members have been paid to make tens of thousands of men impotent. An editorialist in the Annals of Internal Medicine who wrote in support of the USPSTF recommendations quoted Upton Sinclair, who said, "It is difficult to get a man to understand something, when his salary depends on his not understanding it."

So I will start explaining to my male patients the known harms and the unproven benefits of PSA screening. For many patients this will be a slow and difficult psychological shift. Many patients will still request the test out of habit or simply because they don't yet believe the new recommendations. That's fine. They're the boss. I only give advice.

In six years I will turn 50. I tell all my patients that I'll celebrate by undergoing a colonoscopy for colon cancer screening. I will certainly not have my PSA checked.

What we urgently need is a new test that discriminates aggressive prostate cancer from the more common harmless prostate cancer, and we need less harmful treatment options. I have six years to wait for such advances. Meanwhile, a very nice man who has been my patient for over a decade is scheduling his prostatectomy in the next few weeks. I hope he does well.

Learn more:
All Routine PSA Tests For Prostate Cancer Should End, Task Force Says (Shots, NPR's health blog)
Government task force discourages routine testing for prostate cancer (Washington Post)
Men Should Skip Common Prostate Test, Panel Says (Wall Street Journal)
Screening for Prostate Cancer: U.S. Preventive Services Task Force Recommendation Statement
USPSTF author insight video
Prostate Cancer Screening: What We Know, Don't Know, and Believe (Annals of Internal Medicine editorial)
What the U.S. Preventive Services Task Force Missed in Its Prostate Cancer Screening Recommendation (Annals of Internal Medicine editorial)
National Panel Advises Against Prostate Cancer Screening (my post last year about the USPSTF PSA recommendations)

Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000. Holding privileges at Cedars-Sinai Medical Center, he is also an assistant clinical professor at UCLA's Department of Medicine. This post originally appeared at his blog.

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Blogger TrueMed MD said...

PSA screening has eliminated advanced prostate cancer for the most part. However, according to Dr Welch in August JNCI, one million men were overdiagnosed and overtreated for prostate cancer over the last twenty years.

Was PSA Screening for Prostate Cancer a 20 year failed Medical Experiment ?

For More:

jeffrey dach md

July 17, 2012 at 8:20 AM  

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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