In a recent Op-Ed in the NY Times, a non-clinician PhD, announces another fix to the health care crisis. Lets do away with PSA testing and save the government a lot of money! Brilliant, or is it?
Most Urologists in clinical practice clearly remember those days when the wards of a Urology floor were filled with patients dying of prostate cancer. Patients laid in their hospital beds in severe pain from metastatic disease to bone or perhaps were being dialyzed several times weekly as a result of renal failure that occurred due to metastatic lymph nodes from their prostate cancer that would result in obstruction of the urinary tract. Many patients were unable to urinate, and required catheterization. This was a horrendous way to come to the end of ones life, being totally debilitated and succumbing to a slow, painful, torturous end of life. Surprising that the author of The Great Prostate Mistake would knock the use of PSA testing, especially since his father passed away from metastatic prostate cancer.
The current generation of Urology residents rarely observes patients like this any longer. The wards of hospitals are no longer filled with patients dying of prostate cancer. So why has a shift in the way that patients present occurred. PSA testing. PSA testing has resulted in the earlier detection of prostate cancer. All recent criticism of PSA testing has centered on mortality, and not the morbidity that is associated with prostate cancer. Earlier detection of disease and treatment, perhaps has not significantly decreased the overall death rates from prostate cancer, but has allowed numerous patients to avoid the morbidity that is associated with prostate cancer. Bone pain, urinary retention, and renal failure are some of the morbidities that have been substantially diminished.
A good portion of the argument against PSA testing is based on the statement that American men have a 16% chance of being diagnosed with prostate cancer, but only a 3% change of dying from this disease. But that means that 3 of every 100 American men will die from prostate cancer. Doesn’t a 3% chance of dying seem like a lot of people would die from a disease that is potentially curable if detected early enough? Good evidence exists that a rapid rate of change of PSA, suggests the presence of disease. The only way to establish this acceleration is to undergo serial testing. Given that this disease does not cause symptoms in early stages, and the fact that younger men may be afflicted with more aggressive disease, why would we want to not advocate testing in younger men, who are those most likely to benefit from early diagnosis.
Despite what Richard Ablin, the author of the Op-Ed states, most Urologists are a caring, compassionate, and ethical group of physicians. Patients are not automatically pushed into surgery, or intensive radiation. Most treatments are not damaging. In the appropriate clinical setting, surgery, radiation, or cryotherapy are treatments that can be used to provide a cure. Many hours are spent counseling patients regarding treatment options that are available, the possible complications that may be associated with the treatments, the risks and benefits of these treatments, and yes, perhaps to the disbelief of Mr. Ablin, many times the decision is reached for the patient to go into a course of observation.
The American Urological Association has recently (Nov 2009) published the Prostate Specific Antigen Best Practice Statement: 2009 Update. The utilization of these recommendations will result in the responsible use of PSA testing, and will help those patients who most likely will benefit from the use of such testing. Ablin incorrectly states in this Op-Ed that “the American Urological Association advocates universal yearly PSA testing”. In actuality the American Urological Association recommends that men ages 40 and older discuss prostate health and the advantages or disadvantages of PSA testing with their physician.
Knowledge can at times be a dangerous thing, but PSA testing could result in a biopsy (which can be done in a fairly painless manner), that could provide the patient with the information that they need to make an educated decision about the treatment of this disease. Eliminating this type of testing will once again result in many patients suffering from the morbidities that are associated with this disease when it progresses into advanced stages, filling hospital beds, and resulting in extra cost.
True PSA testing is an expensive undertaking. In the upcoming months,
we Americans are going to be forced to answer the question,“At what price health?”!