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Tuesday, October 22, 2013

Free prostate screening! What's the catch?

I just got an e-mail from a hospital where I sometimes practice with a picture of two aging but clearly active and vital men standing on a beach with the words “Free Prostate Cancer Screening” printed below in an attractive font. The hospital is sponsoring the screening, along with the urology clinic affiliated with the hospital. The advertisement gives guidelines for who should avail themselves of this service, including men as young as 35 years old if there is a family history of prostate cancer and otherwise 55 and older, with no maximum age.

Prostate cancer screening, that is checking a man’s prostate cancer via a rectal exam and also performing a blood test for prostate specific antigen (PSA) has been of questionable utility for decades, and finally last year the U.S. Preventive Services Task Force came out with their strongest statement ever, saying they recommended against prostate cancer screening. In prior recommendations they had questioned the utility of screening men at any age and had recommended that men over the age of 75 not be screened. Evidence piled up, however, showing that prostate cancer was significantly overdiagnosed, with many men being diagnosed and treated for prostate cancers which would never have caused them any harm if left undetected, and that the screening process itself, with biopsies and anxiety inducing repeated tests resulted in more harm than any help that would come of early detection. The members of the Task Force, 16 nationally recognized MD and PhD volunteers who specialize in preventive medicine and public health, decided on this basis to recommend categorically against prostate cancer screening.

How is it possible that early diagnosis of cancer is bad? Cancer cells come and go in our bodies all the time. Some of them stay and produce tiny tumors that never cause us harm, others are eliminated by the immune system and by the normal processes of cell aging and death. Only some cancers become evil and endanger or kill us. If we detect the ones that would have caused us no harm, we then get treatment which is painful and harmful, expensive and dangerous. People die of over zealously treated cancers. Some particularly aggressive cancers, if detected early, will still kill us, but we will spend more of our lives having surgeries and chemotherapy than we would have if we had waited until they caused symptoms.

Some cancers, of course, can be caught and eradicated at just the right time and finding these cancers can save our lives. Certain cancers are more likely to be cured when caught early than other ones. Colon cancer is frequently curable if caught early and fatal if allowed to spread. Some breast cancers are that way. Prostate cancer is extremely common as men age, and early autopsy studies concluded that if a man lived to be 100, he would have a nearly 100% chance of having prostate cancer if one were to check his prostate after he died of something else. People do die of prostate cancer, but detecting it early does not seem to make much difference in outcomes, at least not enough difference to outweigh the harms of screening.

This information is not a secret. For a time, the recommendation not to screen for prostate cancer was quite controversial. The American Urological Association, the professional organization of the doctors who biopsy prostates and operate on prostate cancers, did continue to recommend regular rectal exams and PSA testing until the last year or so, when they joined the American Cancer Society in recommending against screening before the age of 40 and after the age of 70, or for men with a life expectancy of less than 10-15 years. For the rest, they recommended screening only after discussing the risks and benefits of doing so with a doctor, with a shared decision making approach involving both science and the patient’s preferences.

I thought perhaps this e-mail I got was an artifact of an earlier age, and that this hospital had somehow failed to hear the news that screening all comers age 35 and above is a bad idea. Then I opened my local paper and found that one of our local hospitals was sponsoring a free prostate screening day with our local urologist. I Googled Free Prosate Screening and came up with over 12 million results, some of which were recommendations against screening, but most were advertisements for free screenings, rectal exams and PSA testing.

Perhaps the urologists are not just doing a rectal exam and a blood test, but are dutifully discussing the risks and benefits of screening and engaging in shared decision making. But I doubt it. This subject takes a long time to discuss and shared decision making requires that the doctor explore the patient’s expectations and values. Free screening clinics usually have lots of people and essentially no time for discussion. Perhaps symptom-free 80-year-olds would be turned away, but I can’t really picture that. Instead I picture a waiting room full of apprehensive guys, many without access to a doctor willing to discuss preventive care with them, being hurried through a brief encounter with a doctor, a quick blood draw and then being handed a few possibly informative booklets which they will most likely never read.

Evaluating for prostate cancer is not a terrible idea if a patient has symptoms that might go along with prostate cancer, things like fatigue and bone pain and sometimes difficulty urinating or blood in the urine. This is not considered screening. This is a well thought out exam to help diagnose a disturbing symptom.

But what if a man just wants to know if he has prostate cancer, and then discuss the options of treating it or watching it with his doctor? Wouldn’t PSA and rectal exam tests be useful for that? Such a can of worms. It is difficult for many men to be comfortable knowing that they have a cancer and not do anything about it. I have had patients who were at peace with this approach, but they were few. In America it is dramatic and somewhat embarrassing to admit to having cancer, but keeping it a secret is difficult too, especially from well-meaning family. Also, having a normal PSA and rectal exam does not mean that a man is free of prostate cancer. Using a cutoff of a PSA of 4, about 15% of men screened with these tests had prostate cancer when biopsies were performed, in a study published in 2004. It is likely more cases would have been found had they used more modern biopsy techniques which sample 8-12 sites rather than the 6 samples taken by old protocols. “Normal” levels of PSA were adjusted down after this, labeling more healthy patients as abnormal.

So, bottom line, free prostate cancer screening is not free. PSA testing and rectal exams are not good ways to detect prostate cancers that would cause harm and could be cured by early treatment. Follow-up PSA testing may or may not help to detect more aggressive cancers but may not be paid for by insurance since PSA testing is deemed not to be very accurate. Prostate cancer is a bad disease, in many cases, and we need to continue to look for ways to detect the cancers that can be cured and effectively treat the ones that cause symptoms. But this does not involve foisting outdated screening routines on an unsuspecting public.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

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Blog log

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.

Auscultation
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.

DrDialogue
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.

FutureDocs
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.

KevinMD
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).

Prescriptions
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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