In the 21st century, medicine has seen unrivaled advances, enabling patient care that includes finding cures for previously incurable diseases. Surgical intervention has moved into a minimally invasive platform, with illness being treated in manners that allows for rapid return to work. Patients in the U.S. are constantly benefitting from the technology that is available; as a result, the American people are living longer, healthier and more productive lives than ever.
Recent events that have occurred on Capitol Hill have threatened to change this. Since this is a urology blog, first allow me to address the United States Preventive Task Force (USPSTF) decision regarding PSA testing. Recently this organization has given PSA screening a “D” rating. The panel has advised against PSA-based prostate cancer screening for men of all ages based on the panel’s moderate certainty that the potential harms of testing outweigh the benefits of testing. The USPSTF has previously warned against mammography for the detection of breast cancer, as well as testicular self-examination for the detection of testicular tumors.
But I suggest that the panel may be telling only half the story. Recently published studies perhaps would alter the decision that the USPSTF have reached, however these studies have not been included in the final decision from the task force. In their decision, the panel mainly focuses on the ability of the PSA test to prevent death from prostate cancer. Yet the recommendations do not address that fact that in 1990, prior to the widespread use of PSA testing 21 percent of men diagnosed with prostate cancer had bone metastasis; today it is only 4 percent. This difference can only be attributable to the use of PSA testing, as it has allowed us to detect disease at earlier stages of disease. Metastatic disease is associated with severe pain that is difficult to relieve and, when it spreads to the bones, can result in fractures of the long bones. More dramatically, it could also lead to the collapse of the spinal cord with nerve compression and possible paralysis. Lymph node involvement can result in kidney obstruction and possible renal failure. These undesirable side effects will certainly again become more common if PSA testing is done away with.
So what is the USPSTF, the organization that is determining the fate of the health of Americans? It is an independent panel of non-Federal experts in prevention and evidence-based medicine. Its present make-up is two professors of pediatrics, two professors of family and community medicine, a director of geriatric research, a professor emeritus of nursing, an associate professor of medicine, epidemiology and biostatistics, an assistant professor of family health, a dean of a college of public health, an associate professor of epidemiology and biostatistics, a pediatrician known for his contributions to Native American health, a public health expert, an assistant professor of OB/GYN, an associate director of a VA health care center, a perinatologist and a professor of medicine.
The obvious question is what experience does this committee have with the detection and the treatment of prostate cancer? When was the last time the perinatologist or an obstetrician/gynecologist took care of a patient with prostate cancer? Common sense would dictate that those who are experienced in prostate cancer diagnosis and treatment should have been involved in the decision-making process. The inclusion of a urologist, a medical oncologist and a radiation therapist would have been an intelligent choice, and perhaps would have allayed some of the indecision.
Presently, urologists - including myself - and the American Urological Association (AUA) are still advocating the use of PSA testing. A recent USA Today survey found that less than 2 percent of primary care physicians surveyed plan to stop using PSA testing. Although PSA testing in not perfect, it is the only tool that we have at present that helps us detect prostate cancer. I advocate a thorough discussion with the patient regarding the benefits (or lack of benefits) associated with the use of this test, and I encourage patients to make the final decision.
Published On: July 09, 2012