Pros & Cons of Screening for Breast and Prostate CancerThe old news, by now a couple of years old, is that the U. S. Preventive Services Task Force (USPSTF) has recommended against routine screening of women aged 40 to 49 years for breast cancer, and also recommended against screening for prostate cancer for men at any age using the prostate-specific antigen (PSA) test.
The newer news is that a lot of the evidence, perhaps most of it, appears to be contrary to the USPSTF’s recommendations. And the big question is, why did the USPSTF come to these conclusions?
Who, or What, Is the USPSTF?
Here’s what they say about themselves:
“U.S. Preventive Services Task Force
The USPSTF is an independent panel of non-Federal experts in prevention and evidence-based medicine and is composed of primary care providers (such as internists, pediatricians, family physicians, gynecologists/obstetricians, nurses, and health behavior specialists).
The USPSTF conducts scientific evidence reviews of a broad range of clinical preventive health care services (such as screening, counseling, and preventive medications) and develops recommendations for primary care clinicians and health systems. These recommendations are published in the form of ‘Recommendation Statements.’
AHRQ’s Prevention and Care Management Portfolio provides ongoing administrative, research, technical, and dissemination support to the USPSTF.
About the USPSTF
The USPSTF strives to make accurate, up-to-date, and relevant recommendations about preventive services in primary care.
To learn more detailed information about the USPSTF, including how it operates, current members and partners, and background information, visit http://www.uspreventiveservicestaskforce.org/about.htm
Methods and Processes
For the USPSTF to recommend a service, the benefits of the service must outweigh the harms. The USPSTF focuses on maintenance of health and quality of life as the major benefits of clinical preventive services, and not simply the identification of disease.”
AHRQ, by the way, is the Agency for Healthcare Research and Quality, which is part of the U. S. Department of Health and Human Services. Nobody, as far as I can tell, has accused either the USPSTF or the AHRQ of not being conscientious and on the up & up. My ornery turn of mind, however, suspects the USPSTF of keeping a sharp eye on healthcare costs in general, and of being perhaps excessively reluctant to recommend treatments or procedures that, although they might benefit some patients, cannot be demonstrated to meet certain standards of cost effectiveness. That might be my prejudice, but let’s see how their recommendations stand up in the light of the evidence.
The Mammography Recommendations
Back in 2002, the USPSTF issued a recommendation for screening mammograms for all women 40 years of age or older. The recommendation went on to say that
“Clinicians should inform women about the potential benefits (reduced chance of dying from breast cancer), potential harms (for example, false-positive results, unnecessary biopsies), and limitations of the test that apply to women their age.”
However, in November of 2009, they issued an update:
“The USPSTF now recommends against routine screening of women aged 40 to 49 years (C recommendation), recommends biennial screening mammography for all women aged 50 to 74 years (B recommendation), and provides an I statement regarding screening for women older than 75 years.”
Here, by the way, if you’re interested, is what the USPSTF says those recommendations mean:
What the Grades Mean and Suggestions for Practice
Grade
Definition
Are you getting our free Daily Update
"reveal" emails? If not,
just click here...Suggestions for Practice
The USPSTF recommends the service. There is high certainty that the net benefit is substantial. Offer or provide this service. The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. Offer or provide this service. Note: The following statement is undergoing revision.
Clinicians may provide this service to selected patients depending on individual circumstances. However, for most individuals without signs or symptoms there is likely to be only a small benefit from this service.Offer or provide this service only if other considerations support the offering or providing the service in an individual patient. The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits. Discourage the use of this service. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.
Talk about carefully hedged! But now, let’s take a look at the “evidence” that they themselves cite:
They base their conclusion on several clinical trials and meta-analyses. (A meta-analysis combines the results from several trials or studies, even if the ground rules by which the trials were conducted are different – i.e., patients of different ages or with different risk factors, etc.) In women in their 40s who were screened via mammograms, the risk ratios for death from death cancer in these studies averaged 0.85, meaning that they had a 15% reduction in breast cancer mortality, compared with the women who had not had mammograms. That’s not nothing!
Here are the pooled results (USPSTF figures) for four age brackets:
Table 1. Pooled RRs for Breast Cancer Mortality From Mammography Screening Trials for All Ages
Age
Trials Included,
nRR for Breast Cancer
Mortality (95% CrI)NNI to Prevent 1 Breast
Cancer Death (95% CrI)39-49 y 8* 0.85 (0.75-0.96) 1904 (929-6378) 50-59 y 6a 0.86 (0.75-0.99) 1339 (322-7455) 60-69 y 2b 0.68 (0.54-0.87) 377 (230-1050) 70-74 y 1c 1.12 (0.73-1.72) Not available
CrI = credible interval; NNI = number needed to invite to screening; RR = relative risk.
* Health Insurance Plan of Greater New York,27 Canadian National Breast Screening Study-1,28 Stockholm,26 Malmö,26 Swedish Two-County trial (2 trials),26,31 Gothenburg trial,30 and Age trial.29
a Canadian National Breast Screening Study-1,28 Stockholm,26 Malmö,26 Swedish Two-County trial (2 trials),26,31 and Gothenburg trial.30
b Malmö26 and Swedish Two-County trial (Östergötland).26
cSwedish Two-County trial (Östergötland).26
The last column is where we find the data that pushed the USPSTF over the edge. NNI, in case you missed the tiny footnote, is the “number needed to invite to screening” to prevent one breast cancer death. Whereas for women aged 60 to 69, that number is 377, and for women aged 50 to 59 it is 1339, for women aged 39 to 49 it is 1904. What the USPSTF is saying is that it’s not worth screening 1904 women in their 40s to prevent one death, whereas it is worth screening 1339 women in their 50s and 377 women in their 60s to prevent one death. It seems to boil down to an economic calculation.
Now, according to the U. S. Census Bureau, in 2011 there were 21,604,000 women in our country between the ages of 40 and 49. My little pocket calculator, which has never lied to me, tells me that if all these women had mammograms, it could result – if you trust those figures from the USPSTF – it could result in preventing 11,347 deaths from breast cancer
I feel like putting that in large bold type: mammograms for women in their 40s could result in preventing 11,347 deaths from breast cancer.
So why did they change their recommendation? Let’s take a look at the “harms” they mention as offsetting the benefits (i.e. not dying of breast cancer). These harms include radiation exposure, pain during the procedure, anxiety and distress, and possible false positives resulting in unnecessary biopsies. They themselves minimize the risk of radiation exposure, note that few women consider the pain as a deterrent from future mammograms, and state that false-positive mammograms had no consistent effect on women’s general anxiety and depression. Are those “harms” enough to recommend that women in their 40s forego a procedure that could save their lives?
In the meantime, what has been happening is that the number of screenings has been declining, and along with that, the number of cancers detected has been declining. For example at the New York Presbyterian-Weill Cornell Medical Center from 2007 through 2010, 43,351 screenings were done and 205 breast cancers were found, 19% of which were in women in their 40s, and half of that 19% were of the invasive type. Those are cancers that spread through the breast tissue rapidly and need to be treated promptly, but, of course, if they are not detected they won’t be treated. In another study, researchers found that mammograms increased at a rate of 0.9% yearly from 2006 to 2009, but when the USPSTF recommendations were issued in 2009, the rate of mammography declined by 4.3%. That means fewer cancers detected, fewer cancers treated, and more deaths.
My take on this: the recommendations of the USPSTF in this particular case have done more harm than good.
And Now, What About Prostate Cancer Screening?
That issue is a good deal more complicated, and I won’t be doing anyone any favors by waltzing over the difficulties. These come bubbling up from two sources – one, the disease process itself, and two, the nature of the prostate specific antigen (PSA) test.
Here’s the thing about prostate cancer: it mostly affects older men, and it progresses fairly slowly. The statistics are illuminating. The median age for diagnosis of prostate cancer is 66, less than 1% of the cases are seen in men younger than 44, and less than 10% in men younger than 54. According to SEER data (Surveillance Epidemiology and End Results, from the National Cancer Institute), prostate cancer mortality is 23 per 100,000, but in black men it’s more than double that – 50.9 per 100,000. The reasons for this huge discrepancy are not entirely clear, but the guess is that it has a lot to do with both treatment and screening.
In many cases prostate cancer progresses quite slowly. The common wisdom is that men die with it, but not of it. Something else gets us first. However, this may be changing – as mortality diminishes from other common diseases such as heart disease and stroke, many men live longer, giving even slow-growing prostate cancers time to grow and become fatal.
And, here’s the thing about the PSA test: it’s not very good, either in terms of sensitivity or specificity. The test has been in use since 1986, and for much of that time doctors thought that a level of 4.0 ng/mL (nanograms per milliliter) was the cut point for a follow-up. However, men with a condition called benign prostatic hyperplasia (BPH) can have elevated PSA levels, as can men with urinary tract infections. And some men can have prostate cancer without having elevated PSA levels. So, what’s to be done? Toss the whole thing in the garbage can and trust that we’ll be struck by lightning before prostate cancer gets us?
That’s not quite what the USPSTF says, but it amounts to the same thing:
Screening for Prostate Cancer
Current Recommendation
Release Date: May 2012
- The USPSTF recommends against PSA-based screening for prostate cancer.
Grade: D Recommendation.
This recommendation applies to men in the general U.S. population, regardless of age. This recommendation does not include the use of the prostate-specific antigen (PSA) test for surveillance after diagnosis or treatment of prostate cancer; the use of the PSA test for this indication is outside the scope of the USPSTF.
“Prostate cancer is a serious health problem that affects thousands of men and their families. But before getting a PSA test, all men deserve to know what the science tells us about PSA screening: there is a very small potential benefit and significant potential harms. We encourage clinicians to consider this evidence and not screen their patients with a PSA test unless the individual being screened understands what is known about PSA screening and makes the personal decision that even a small possibility of benefit outweighs the known risk of harms.” —USPSTF Co-Chair Michael LeFevre, M.D., M.S.P.H.
May 22, 2012
There’s no denying the potential “harms” that come with PSA testing. If the test is positive, chances are a biopsy will be ordered. If the biopsy is positive (as evaluated by something called the Gleason score, which I’ll talk about in another piece), chances are some kind of treatment will be recommended. And treatment, whether surgery or radioactive seed implantation, is not without consequences. But the alternative, including 28,170 expected deaths for the year 2012, is not preferable.
The Evidence Regarding PSA Testing and Prostate Cancer Treatment
First, let’s look at the evidence marshaled by the USPSTF in their full report. The basis for their recommendation was that although “screening based on PSA identifies additional prostate cancers, most trials found no statistically-significant effect on prostate cancer-specific mortality.” The report cites two trials to answer the question whether PSA screening decreases prostate cancer mortality, both of these described as being of “fair quality.” One of these, conducted in the US, followed 76,693 men for 7 years and found no significant difference between men assigned to PSA screening and those assigned to “usual care,” meaning no screening. However, it turns out that of the men in the usual care group, 44% had had a PSA test before entering the trial, and 52% had a PSA test at some point during the trial. That’s what you would call a thoroughly tainted control group. So they were basically comparing men who were supposed to have had PSA tests with men who were not supposed to have PSA tests, but many or most of whom had PSA tests anyway.
The other trial, a multicenter European trial, found that PSA screening every 2 to 7 years was associated with a 20% relative risk reduction in a subgroup of 162,243 men aged 55 to 69 years.
That’s not nothing.
However, there’s more. One of the participating centers, in Sweden, decided to publish their results separately. PSA screening every two years in a group of 20,000 men resulted in a decreased relative risk for prostate cancer mortality of 44% after 14 years of follow-up. That’s quite a lot more than nothing.
From my perspective, trying to trace the link between PSA-based screening and ultimate prostate cancer mortality or survival leaves out way too many intervening steps. The studies cited by the USPSTF used a number of cut-points for the PSA test, ranging from a low of 2.5 ng/mL to a high of 10.0 ng/mL, to determine the need for further evaluation, meaning needle biopsy. The studies all found that screening led to increased “incidence of prostate cancer,” meaning that more cancers were diagnosed, no surprise. But what then? What factors guide the decision on whether to treat, and what form of treatment? The USPSTF report is silent on this.
However, their review of data from studies comparing prostatectomy with watchful waiting found that prostatectomy was associated with “a sustained decrease in risk for prostate cancer-specific mortality (15% vs 21%, RR 0.62 [CI 0.44 to 0.87].” That means that men who opted for watchful waiting had about one-and-a-half times greater risk of death from prostate cancer than men who had prostatectomies. There was also a 25% lower risk for all-cause mortality, and among men less than 65 years of age, the relative risk reduction was 51% for prostate cancer mortality and 48% for all-cause mortality. The report also cites 8 cohort studies that consistently found prostatectomy associated with lower all-cause mortality (54% lower risk) and prostate-cancer mortality (68% lower risk).
At this point, my eyes are bugging out. How do you get to the point of deciding on a prostatectomy without previously having arrived at the diagnosis? How do you achieve that considerably lower risk of prostate-cancer mortality without previously having done the PSA screening?
The USPSTF did not take into consideration the very strong association between a man’s initial PSA score and his risk of death from prostate cancer. If a man’s first PSA score is between 4.0 and 9.9, his risk of death from prostate cancer is three times higher than that in a man whose first PSA score was less than 2.5. And if the first PSA score was 10.0 or higher, the risk of death is eleven times higher. This study, from the Duke University Prostate Center points to the desirability of starting to track the PSA score earlier in life, so that men with rapidly rising PSA scores can be identified. One fundamental anti-PSA-testing argument is that it is difficult to distinguish aggressive from indolent prostate cancer, but the association between the first PSA score and prostate cancer death strongly suggests that rapid increases in the PSA point to aggressive cancers.
In other words, the best practice may well be, start getting your PSA tested earlier, establish a baseline, and then monitor it. Not to do that seems to me to mimic the ostrich strategy for avoiding trouble.
And by the way, it’s worth noting that while the overall incidence of prostate cancer in the US is flat, the mortality rate is steadily declining – at about 3.9% per year, according to the CDC. To what might we attribute that? To watchful waiting?
I doubt it.
In short, we have to give the USPSTF credit for honestly reporting all the data that shoots their conclusion full of holes. Maybe they figured that it would be enough to release their recommendations to the media (as they did with their recommendations regarding mammograms) and hope that nobody would bother to read the fine print.
Finally, a paper in the journal Cancer published in August of 2012 reported that the incidence of metastatic prostate cancer on presentation would triple, from the current rate of 8000 cases per year, to an estimated 25000 cases per year if men did not get PSA tests. They did this by comparing the mean annual incidence of metastatic cancer in the last years before PSA testing became widespread (1983 – 1985) with the incidence rate in the most recent year for which there were data.
By the way, according to SEER, for the 93% of cases detected where the cancer is localized or regional, the 5-year survival rate is 100%, whereas for the 4% with metastasized cancer at diagnosis, it’s 27.9%.
I think those papers definitively discredit the USPSTFs anti-PSA test stance. You’d think they were trying to launch a job-creation program for undertakers.
* * * * * * *
As I said in my previous piece, I’m not a doctor, and I wouldn’t presume to give medical advice. My qualifications for scrutinizing and evaluating the pronouncements of organizations, whether government, academic, Big Pharma, or alternative health care, consist of a pretty good scientific background and a deep-dyed cussedness of character that disposes me to pick things up and look at their undersides. I look forward to your comments on this piece, and I’ll try to answer questions and say more about the current state of cancer treatment in a future piece.
Michael Jorrin (aka Doc Gumshoe)
thanks for a great article, when I read the baloney on the net about PSA screening being useless i just shook my head. my case is exactly what you talked about, early tests to establish a baseline and then a bio when the change was significant from one year to another and double radiation therapy, seeds and external beam. based on a hugh database I have a 90% 10 year survival rate because the gleason number was aggressive. no side effects from the radiation 3 years since treatment.
Eight years ago I feel certain my life was saved by the PSA and a damn good urologist. For five or so years I had suffered from BHP and at that time we started watching the PSA. Eight years ago there was a spike in my annual test and my urologist took a sample for biopsy. It actually involved taking little strings of tissue from six areas of the prostate. The biopsy showed the presence of pre-cancerous tissue so we agreed to repeat the biopsy after six months. The new test revealed the presence of cancer but it was contained to 5% of the gland. The Gleason numbers were moderately aggressive and I opted for prostatectomy. In the eight years since then my annual PSA has been right at 0 and it appears that my chances of metastasis are virtually nil. I think the moral of my story is that if you experience a spike in your PSA, get a biopsy – it can be done very easily via sampling through the sigmoid wall of the bowel. The point is that had we not done the PSA testing we would not have done the biopsies either and my cancer would have had a much greater chance of metastasis to the lungs or elsewhere.
I have a question that is slightly tangential to the discussion concerning breast cancer screening.
It is my understanding that thermal mamography, as compared to conventional mamography, is far least invasive, completely eliminates radiation exposure, significantly reduces false positives, and is much less costly.
Can you confirm this?
John Saggese
Perhaps, I could shed some light on this.
Thermography measures infra-red radiation emitted by the human body. Cancer cells, that are metabolically active, are ‘hotter’ than the surrounding tissue, and can yield information about cancerous (and some suggest pre-cancerous lesions).
Pros of thermography:
a) Non-invasive
b) Yes, it does not use ionizing radiation, and
c) Sensitive
Cons:
Scientifically, in the past, thermographic methods were considered very ‘sensitive’ (i.e., for the detection of disease), but were not ‘specific’ (i.e., there were too many false positives).
Recent advances in digital infra-red cameras (that do not require cryogens) have substantially increased the stability and precision of temperature measurements. However, I am not aware of any trials that are conducted to consider the use of thermography for breast cancer screening.
Some targeted research groups use thermography in conjunction with mammography to improve the sensitivity/specificity of breast cancer detection.
Thanks, Raja:
Could I interpret that to mean “it MIGHT be better, but hasn’t been proven yet”?
Any info on the comparative costs?
Thanks again,
John Saggese
John:
Yes, I think it is an accurate summary.
I do not know what they charge for these tests. I am guessing that they would charge somewhere in the ball-park of $100-$200 including the interpretation.
If you plan to seek out thermography as a screening tool, I would suggest going to a center that has good quality control programs in terms of patient preparation, and a systematic review or diagnostic read of the images. Most radiologists are not trained in the interpretation of thermograms as this is not a reimbursable procedure.
Thanks again, Raja:
This isn’t for me. But, I have a wife, a daughter, two daughters-in-law, and 6 grand daughters, so this subject is of real importance to me.
Best wishes,
John
I am a retired physician; I would recommend finding out as much as you can about family history concerning cancer. Not smoking, not drinking excessively, after the age of 50 bring a stool specimen to be tested for blood, wearing sunblock, a broad brim hat during sunny days, getting a colonoscopy when recommended. Making sure family physician does a proper physical. Monthly self breast exam for women over 20 (almost as good a mammogram and free. Yearly CBC and chem profile.
tell steve jobs and linda mac cartney
Steve Jobs had pancreatic cancer; no good inexpensive screen for that. Also pancreatic cancer does not produce symptoms until too late. No screening test is perfect. But the above will save lots of lives.
Don’t smoke, don’t smoke and don’t smoke.
I believe that you can do all the radiation , chemical , cutting , burning , implant nuclear seeds into your body – (How F’N nuts is that) suffer all these treatments only to have to repeat them again until you are dust. A better way — Get your mind right – by using Far Eastern Meditation Techniques – Use ETF Therapy by Gary Craig – Yoga etc . and then go organic food (NO GMO) – juicing and do research of what herbs , fruits , vegetables work best against the type of cancer you have. Example – Cruciferous Vegetables for breast , ovarian cancers . Essiac Teas for lung and breast cancers – Saw Palmetto for Prostate – Etc Etc.
Get a juicer and juice for your life everyday and you must exercise everyday do something to get your cells pumping – Do this for 6 weeks and you will be on your way to true health – body mind and soul !
Cancer sucks – and I have been burnt , frozen , cut on , and chemically poisoned and it wasn’t until I did all of the above that I had success in curing myself or I know I would not be typing this now! My energy is off the charts , I can do things I haven’t been able to do for 30 years & I remain cancer free and have no doubt I will always be. Hope this helps someone
VERY sage advice Sonny!!!
Hope everyone heeds it!!!
Lorraine Day MD has quite a story to tell on youtube about her recovery from stage four breast cancer.
Bruce hit the nail on the head for me also. Establish the baseline and it becomes obvious when the biopsy is needed.
I was asymtomatic when I had a PSA… It returned a level of 15… on biopsy I had a Gleason of 7,,, Had a cryoabaltion of the prostate and now 2 years later I have a PSA of 0.1… I’ll go with the testing…
As a physician I share your dismay and cynicism regarding the USPSTF mammography and PSA testing recommendations. As a retired radiologist I can speak more knowledgeably about mammography. If there are 21,604,000 women in our country between the ages of 40 and 49 not receiving mammograms, that is an avoided cost, at $100 per mammogram (a fairly conservative cost estimate), of $21,604,000,000. Of course not all woman avail themselves of a mammogram, so lets cut the savings in half, assuming only 50% of women in that age group get a yearly mammogram and you have an avoided cost of 10 billion dollars yearly. 10 years of avoided mammograms for a woman aged 40-49 in each of those years equals 100 billion dollars of avoided cost. 11,347 lives saved would be at a cost of $8 million or so dollar per life saved. Is cost effectiveness affecting the U.S. Preventive Services Task Force recommendations? You bet! The United States Preventive Services Task Force (USPSTF), “an independent group of national experts in prevention and evidence-based medicine.” is just a stalking horse for Obamacare’s coming Independent Payment Advisory Board (IPAB), an unelected body with powers so broad that it has been called a “super-legislature” by some, and a potential “death panel” by others. Major policies set by the IPAB will have the force of law unless they are explicitly blocked by Congress! The USPSTF “recommendations” will become the law under the IPAB. Take medical advice from your doctor, not a bureaucrat, while you can! To the bureaucrat you are just a statistic, a “cost”, not a person!
I would have to respectfully disagree with the good doctor regarding USPSTF.
First, let us dispose the conspiracy theory and the Obamacare bogeyman regardign USPSTF. The USPSTF was established in 1984, and since 1998, the Agency for Healthcare Research and Quality (AHRQ) has been authorized by the U.S. Congress to convene the Task Force and to provide ongoing scientific, administrative, and dissemination support to the Task Force. They are not exactly new and specifically tied to Obamacare.
Second, Dr. Borsuk, correctly estimates the cost of the screening mammogram for the women between the ages of 40-49 to be somewhere between $21 billion dollars (100% participation) to $10.5 billion dollars (50% population) per year. So, over 10 years, the avoided cost will be in the neighborhood of $210 billion dollars to $100 billion dollars. This is just the screening cost. The other significant cost to the equation are the following:
a) Overall 10% of the population that undergoes screening is recalled for additional testing. Only 5% of the recalled population, or 0.005% of the original population will have cancer (http://www.cancer.gov/cancertopics/pdq/screening/breast/healthprofessional/#Section_20).
Additional testing may involve biopsies, or MRI tests, that are significantly more expensive than mammography. Furthermore, over a 10 year period, one out of two women (50%) will undergo additional testing. The total healthcare dollars spent will be easily double or triple the amount. This is an issue of the poor specificity of mammography.
b) How about the flip side of the equation i.e., the sensitivity of mammography? Mammography has poor sensitivity (the ability to detect disease when it is present) particularly in young women with dense breasts, or specific types of cancer (mucinous,lobular cancers). It has been reported that 6-46% of women with invasive cancer can have normal mammograms. So, even if you screen for breast cancer, every women, every year above the age of 40, you will miss detecting a significant number of invasive breast cancers.
Mammography is not a holy-grail when it comes to screening of breast cancer. It has its pluses and minuses, and in my view USPSTF made an informed recommendation. Is cost a consideration in the recommendation? Of course, it is part of the consideration, for any screening test. If money were not an issue, then one should do screening MRIs for every single women, every single year. The sensitivity and specificity are higher, the risks are lower, etc. We don’t do that do we?
If, we as a society, consider that we should be willing to spend $200-$300 billion dollars for screening for breast cancer per year, it is fine. Then, we should have that discussion for every screening test, prostate cancer, colon cancer, etc, then we should debate this issue openly, and decide how, and who is going to pay for it, and the ramifications of this thought process. Other countries, e.g., scandinavian countries, have had that discussion and have come to an agreement regarding the societal cost/benefit of screening and the tax that they are willing to pay. We are just starting that conversation in the US.
Until low-cost screening tests with high diagnostic accuracy are developed the issue of cost for any population based screening test is a legitimate and valid one, and we should not shy away from it, and not cast aspersions on those who are trying to provide that information.
The truly unseen and fundamental problem with the above analysis is that it is totally dependent on societally funded (ie government) health care. For manyt years I paid for medical insurance that provided protection for significant procedure costs. I also paid directly for minor diagnostic test costs. (I am now 79)–When I got hurt as a child, my parents took me to the doctor and paid for the visit. All these direct costs were reasonably affordable. Now that we depend on bureaucracies for payment, two things have happened. One is that medical costs have spiraled upwards, the other is that we are no longer responsible for ourselves. It’s stupid, nd we’re stuck with it. (Don’t forget the effect of the army of self-interested lawyers.)
Fun seeing you look into medical claims the way you look into trading claims, but I have come to no conclusions regarding the tests referenced.
I do believe, however, in doing early testing to establish baselines, along with everything Solyom talks about. Baselines can signal a change that a one-time test will not, and, just as important, they can reveal a false positive.
Real important to establish a good, long-term relationship with a physician you respect, and get all the tests you feel strongly enough about to be willing to pay for.
Why are people so obsessed with “Obamacare”? You will always be able to get any service you are willing to pay for. I would think the people who subscribe to this newsletter are all about making sure they have enough money to pay for what they want.
Thank you for sharing your research on this. Great job!
The doctor who invented the PSA test says it is useless for initially detecting prostate cancer due to the false positives. Heck, if you ride a bike or have an ejaculation within 48 hours of having the test, it probably will be positive.
As for mammograms – the procedure itself can rupture a tumor. Self examination works as well, without the false positives and dangers. If a woman detects a lump, THEN do the mammogram.
And Angelina Jolie is a nutcase.
A Canadian study did just that and got very good results.
Travis, thank you for the article. As a Prostate Cancer survivor, and student of the disease, I can personally say that you are spot on! And Dr. Borsuk above is also correct in his reply.
I have found that unfortunately there are many men who embrace the “ostrich” approach when confronted with a test that MAY detect prostate cancer. PSA is simply a blood draw and analysis that if followed as Travis says, watching for an increasing trend and a jump above the 4.0 ng/mL level, could very well save your life. Choosing the type of treatment is another story. That is why if diagnosed you MUST become a student of the disease.
I am alive because of the psa test so is my brother.
Needs no elaboration.
There will always be people who benefit from “incidental” early diagnosis, e.g. finding a small peripheral lung tumor on a CT scan done for some other reason. Similarly, if everyone in the country had a whole body CT scan, lots of unsuspected cancers would be found and a few lives would be “saved” and a few people would have a cancer induced by exposure to radiation and a few would die (or be impotent or incontinent) from invasive procedure done to confirm (or not) the diagnosis. It all depends on which of those people you are as to how you look at it. We cannot use these “stories” to develop public policy. Screening involves testing people who are not sick and most tests will be negative, hence a cost-benefit analysis is always appropriate.
I worry about the financial future of the authors of some of these murky comments about screening tests. A radiologist makes money interpreting these tests and his comments should rightfully be viewed with some skepticism. And lastly, Ms Jolie is not a nutcase but a wise and beautiful woman who went public with a painful story that is heart-wrenching to most women. I would call her heroic.
Michael Jorrin:
Your article about breast and prostate cancer screening is well intentioned, but I wonder, if you are distinguishing between two statistical terms – relative risk, versus absolute risk.
Relative risk reduction of 15% sounds like a big reduction in risk with screening, but let us put this in context. The numbers used below are actual rates from published literature for women between ages 40-49.
If you take a pool of 10000 women (age between 40-49), and do NOT perform mammography for 10 years, 32/10,000 will develop breast cancer or 0.32% in this population.
You take another pool of 10000 women (age between 40-49) and perform mammography for 10 years, then 27/10000 will develop breast cancer or 0.27% of the population ( a relative risk benefit of 15%).
So, the absolute reduction in risk is 0.05% (or a relative risk benefit of 15%), or 1 in 2000. In other words, 2000 women should be screened every year for 10 years, to reduce the
Now, let us look at both groups, and see how many of them would die of breast cancer. In the second group of 10,000 women, 20/27 women would still die of breast cancer.
Please note that I am not saying that mammography is not a useful tool, but only that people should clearly understand the difference between relative risk versus absolute risk when discussing these issues. As an individual, when the data is presented in a more descriptive way, patients will make an informed choice regarding their health.
The following paragraph was incomplete, and should have ended as below:
“… So, the absolute reduction in risk is 0.05% (or a relative risk benefit of 15%), or 1 in 2000. In other words, 2000 women should be screened every year for 10 years, to prevent one women from breast cancer death”.
Just wanted to offer the other side – two brief articles based on the writing of an alternative health provider, Dr. David Williams. While Gumshoe disects the mortality issues, he never touches the ill side effects of treatment and even biopsy. And I note that after having the prostate removed it is not surprising your risk of death from prostate cancer is lower than for those who still have theirs – I mean duh. Of course it is but that does not mean we all should get our prostate removed – the side effects – impotence or worse wearing a diaper are not worth it.
Misleading PSA Tests
Over the last twenty years screening for prostate cancer in older men has become very common, using a PSA test (prostate specific antigen). Dr. Thomas Stamey of Stanford University was initially a strong advocate for PSA testing, but now says that PSA test are no longer useful or a reliable marker for detecting prostate cancer. (1)
PSA is a glycoprotein that is secreted by normal prostate glands. Blood levels of it will increase if the prostate gland enlarges even if there is no cancer present. Aggressive cancers of the prostate do enlarge it and raise PSA, but a large majority of all men have benign, non-cancerous enlargement of the prostate as they age, particularly after age 50(2). Since this also raises PSA levels Dr. Stamey found that elevated PSA levels relate to cancer only 2% of the time. The public has the misconception that a high PSA level means you have prostate cancer. The result is far too many unnecessary biopsies of the gland.
To make matters worse, by the time men become elderly virtually all will develop small extremely slow-growing cancers in their prostate gland. In most men, however, they grow so slowly that men die of other causes long before the prostate cancer would need treatment. But with so many biopsies being done for high PSA levels raised by benign enlargement, not by the small cancers, the small cancers are nonetheless detected and prostate glands are surgically removed. Between unnecessary biopsies and the removal of the prostate gland thousands have suffered with subsequent hormone problems, sexual dysfunction, incontinence, and related distress and anxiety. Speaking before the American Urological Association recently Dr.Stamey said, “…PSA no longer has a relationship to prostate cancer. Because we all develop the cancer, we’re now removing prostates from men whose cancer is so small that they do not need the procedure. We’re finding all these little cancers that are never going to be a danger to the patient.”(3) Instead of the PSA test, Dr. Stamey recommends the old fashion rectal exam with a gloved finger and a medical history to monitor prostate health.
Alternative providers certainly advise men to see their medical doctor regarding most questions about their prostate. However, they strongly suggests that before you consent to any surgical procedure on your prostate gland, even a biopsy, that you discuss this article with your medical doctor and as with all surgeries, get a second opinion.
(1) D. Williams, “PSA is a Pretty Silly Argument,” August 2004, Alternatives, Mountain Home Publishing, Potomac, MD, Vol. 10, No. 14, p. 109.
(2) Because the prostate gland encircles the urethra as it enlarges it can constrict the urethra causing reduced urine flow, urgency, and frequent urination at night, because the bladder does not fully empty.
(3) D. Williams, Op. Cit
Say No to PSA Testing.
The prostate specific antigen (PSA) test for detecting prostate cancer in men may do more harm than good. This test, widely rejected in Europe, became popular here despite little legitimate research showing it saves lives. In a recent study of some 76,693 men about half of them got yearly PSA testing, the other half did not. Those who were diagnosed early with PSA tests had essentially the same death rate from prostate cancer as those that never had the test(1) (for the study – Gumshoe points out they many had a PSA test prior to the study but that does not discount the findings of the study). In reality prostate cancers often grow so slowly that they cause no symptoms, go undetected, and the men die of other causes.
When PSA tests are positive, the next step is usually a needle biopsy. The needle can easily miss a small cancer confined to a small part of the prostate but it the needle does find a cancer the needle, as it is withdrawn, cans spread cancer cells into the blood and other parts of the body creating a much bigger threat than cancer that was contained within the prostate.(2)
So the screening saves no lives, the biopsy that comes next has its own problems, but then should they detect cancer, treatments are usually begun (surgery, radiation, etc) that are anything but harmless. Side effects include impotency, urinary problems like incontinence, bowel problems, infertility, breast enlargement and hot flashes, all of which can dramatically reduce quality of life, and treatment can even be fatal. (3) Indeed the same study found that deaths from anything other than prostate cancer was much higher for those getting the PSA tests (312 versus only 225 in the untested group) suggesting just treating cancers that did not need treatment killed many of the men. (4)
The PSA test actually does not detect cancer. It detects a protein that the prostate produces when it is inflamed. Inflammation may eventually lead to cancer and certainly does in other parts of the body just like smoking inflames the lungs and leads to cancer. Inflammation of the prostate however can be treated with natural means. There are a number of nutrients that are effective including saw palmetto, pygeum, and rye grass pollen.(5) These are often combined in prostate health products along with other vitamins and minerals that support prostate health.
Most men, if they live long enough will develop an enlarged prostate, inflammation, and indeed even cancer if they do nothing about it so a good recommendation is that all adult men take a good prostate health product every day, for life.
(1) New England Journal of Medicine, 2009, Vol.360, pp. 1310-1319 (as reported by D. Williams, “The Prostate Cancer Machine,” August 2009, Alternatives, Mountain Home Publishing, Potomac MD, Vol. 13, No. 2, p.10).
(2) D. Williams, “The Prostate Cancer Machine,” August 2009, Alternatives, Mountain Home Publishing, Potomac MD, Vol. 13, No. 2, p.11.
(3) Ibid., pp. 10-11.
(4) Ibid., p. 11.
(5) Ibid., p. 13.
You might want to check out a Canadian company called Mitomics Inc. that has developed a new prostate test that is more sensitive and does not have a false positive problem. It is still an early stage company [not publicly traded] but has started selling. It would be interesting to hear your thoughts on the science.
Complicated issue for sure. I agree that a biopsy can spread cancer cells and metastatic lesions are to be avoided at any cost. But there should be far more emphasis on natural cures. OK, I am immediately classified as a nut job. But please hear me out. I was diagnosed with small cell lung cancer in 2001. That cancer is virulent and the mortality rate is 98%. I was subjected to an agonizing 10 months of horrible chemo drips, repetitive chest radiation and also brain radiation. With the repetitive CT scans, drips, and radiation, I am sure my insurance paid at least $75-100 K. I was devastated and weakened beyond belief for 10 months and then it came back! No further treatment possible now (except palliative). It was either find an alternative or start digging a hole. I chose to be treated by a particular Mexican cancer clinic using immuno-therapy and diet. A month later I left in full remission and remain so (thank God).
I believe much more effort should be made to identify and use natural cures. Of course, don’t expect the drug companies to jump on it. Most natural cures are extremely cheap and can’t be patented. My favorite vaccine costs only about $100 and requires only two injections. Unfortunately, you have to leave the country to have it.
Anyone interested should check out my site and video at http://www.SurvivingSmallCell.com as the treatments I received apply to nearly all cancers. No biopsy is necessary to detect the location or type of cancer. Your immune system does the trick and it doesn’t care what or where.
Natural Prostate cancer treatment may be a good thing regardless of the U.S. Preventive Services Task Force has to say . No surgery, no biopsy, no chemo or radiation. Just natural treatments and diet.
Many thanks for the interesting and thought-provoking commentary in response to Doc Gumshoe’s article about mammograms for women in their 40s and PSA screening for men. I’m firm in my conviction that the USPSTF is more focused on the macro view, with health-care economics as their main concern, than with the decisions of individual patients and their physicians. The careful comments from Raja Muthupillai reinforced the importance of economics on recommendations regarding screening. However, omitted from consideration are the very real and potentially enormous treatment costs associated with missed diagnoses. Mere life and death issues aside, it is obviously much less expensive to find a tumor and remove it quickly than to let it spread and metastasize, and then provide costly terminal treatment to that unfortunate individual.
I’m noting the many interesting questions raised in response to the microblog and will dig into them in future posts. I remain a disciple of my 11th grade math teacher, Miss Charlotte Truesdale, whose testy response to students who “just didn’t get it” was, “Use the brains God gave you!” – Michael Jorrin, aka Doc Gumshoe
Thank you for writing about interesting issues. With respect to screening tests, one should carefully evaluate what is the specific evidence supporting the widespread use of that test. The evaluation should be based on:
(a) Diagnostic screening tests are most useful when both their sensitivity, and specificity are high, and their utility decreases as the sensitivity and specificity gets lower.
(b) Risk/Benefit evaluation of the test in terms of reduction in absolute risk, cost, and additional risks associated with the test weighed against the potential benefits.
Unfortunately, both prostate cancer, and breast cancer screening are emotionally charged issues that often make it difficult to have a dispassionate discussion.
I was traveling when I read the original and now have caught up to the comments as well. I would like to add a few points based on my own and my wife’s experience with cancer.
First, All tests are information and can be extremely important to making decisions. Bean counters deal with statistics so it is up to you to be proactive about your own health. Listen to no one and everyone but be proactive.
Alternate medicine seems to work for some and not others. Linda McCartney and Steve Jobs tried it to no avail. Close friends of mine tried as well with no positive result. However, it may help some people. Acupuncture was a wonder to me when recuperating.
I don’t doubt what people report but I have a lot of faith in Biotech based on positive results for my wife who was HER2 breast cancer. Herceptin saved her life and there are new immunotherapy drugs coming on line shortly.
I know this has drifted off the original article but it is meant as a response to the comments and to underscore the original issue of tests. Do the tests, do the homework on what they mean and stay on top of your doctor. Nobody cares more or can do more for you than yourself.
BIG THANKS for the original piece. It is an important discussion.
Conventional care doesn’t work for everybody either. You have to consider that most of the people going to alternative care have already been treated unsuccessfully and in many cases very much damaged in the process.
So to say “It works on some and not on others” is really meaningless. Remember this, curing a reasonable number of End Stage patients is 100% better than certain death for those patients. I am one of them
The nay sayers always point out the celebs that pass on after trying alternative care. How about all the other people that survive because of it. A lady I know who was given up on due to her diagnosis of Stage 4 breast cancer with mets to the liver and lung. Six months later, she is in full remission and back to work.
The real irony is this: Having survived a 98% fatal cancer using alternative care after the conventional care failed, all of my doctors are astounded by my success, yet not one has ever asked me how it was achieved.
There is no evidence that the small amounts of radiation involved in screening can add in any significant degree to the likelihood of a person getting cancer. Radiation used in therapy is a totally different story. It is also focused on the known cancer location. That is very different. But using radiation exposure as a threat and a reason to avoid screening is just adding to popular radiation scare tactics and should be ignored.