Great Article About PSA in NYT

pathstudent said:

THis is from the pathologist who discovered PSA. It is a disgrace how it is used, and how urologists and pathologists "milked" the system by generating those "12 quadrant" biopsies to maximize the bill when they can just have easily been put in one container or two and lowered the pathology bill by a 12th or a 6th. I have seen patients go to prostatectomy with 2% in one core and it didn't have anything to do with it being in the left lower base or whatever.

http://www.nytimes.com/2010/03/10/opinion/10Ablin.html

By RICHARD J. ABLIN
Published: March 9, 2010
Tuscon


EACH year some 30 million American men undergo testing for prostate-specific antigen, an enzyme made by the prostate. Approved by the Food and Drug Administration in 1994, the P.S.A. test is the most commonly used tool for detecting prostate cancer.

The test’s popularity has led to a hugely expensive public health disaster. It’s an issue I am painfully familiar with — I discovered P.S.A. in 1970. As Congress searches for ways to cut costs in our health care system, a significant savings could come from changing the way the antigen is used to screen for prostate cancer.

Americans spend an enormous amount testing for prostate cancer. The annual bill for P.S.A. screening is at least $3 billion, with much of it paid for by Medicare and the Veterans Administration.

Prostate cancer may get a lot of press, but consider the numbers: American men have a 16 percent lifetime chance of receiving a diagnosis of prostate cancer, but only a 3 percent chance of dying from it. That’s because the majority of prostate cancers grow slowly. In other words, men lucky enough to reach old age are much more likely to die with prostate cancer than to die of it.

Even then, the test is hardly more effective than a coin toss. As I’ve been trying to make clear for many years now, P.S.A. testing can’t detect prostate cancer and, more important, it can’t distinguish between the two types of prostate cancer — the one that will kill you and the one that won’t.

Instead, the test simply reveals how much of the prostate antigen a man has in his blood. Infections, over-the-counter drugs like ibuprofen, and benign swelling of the prostate can all elevate a man’s P.S.A. levels, but none of these factors signals cancer. Men with low readings might still harbor dangerous cancers, while those with high readings might be completely healthy.

In approving the procedure, the Food and Drug Administration relied heavily on a study that showed testing could detect 3.8 percent of prostate cancers, which was a better rate than the standard method, a digital rectal exam.

Still, 3.8 percent is a small number. Nevertheless, especially in the early days of screening, men with a reading over four nanograms per milliliter were sent for painful prostate biopsies. If the biopsy showed any signs of cancer, the patient was almost always pushed into surgery, intensive radiation or other damaging treatments.

The medical community is slowly turning against P.S.A. screening. Last year, The New England Journal of Medicine published results from the two largest studies of the screening procedure, one in Europe and one in the United States. The results from the American study show that over a period of 7 to 10 years, screening did not reduce the death rate in men 55 and over.

The European study showed a small decline in death rates, but also found that 48 men would need to be treated to save one life. That’s 47 men who, in all likelihood, can no longer function sexually or stay out of the bathroom for long.

Numerous early screening proponents, including Thomas Stamey, a well-known Stanford University urologist, have come out against routine testing; last month, the American Cancer Society urged more caution in using the test. The American College of Preventive Medicine also concluded that there was insufficient evidence to recommend routine screening.

So why is it still used? Because drug companies continue peddling the tests and advocacy groups push “prostate cancer awareness” by encouraging men to get screened. Shamefully, the American Urological Association still recommends screening, while the National Cancer Institute is vague on the issue, stating that the evidence is unclear.

The federal panel empowered to evaluate cancer screening tests, the Preventive Services Task Force, recently recommended against P.S.A. screening for men aged 75 or older. But the group has still not made a recommendation either way for younger men.

Prostate-specific antigen testing does have a place. After treatment for prostate cancer, for instance, a rapidly rising score indicates a return of the disease. And men with a family history of prostate cancer should probably get tested regularly. If their score starts skyrocketing, it could mean cancer.

But these uses are limited. Testing should absolutely not be deployed to screen the entire population of men over the age of 50, the outcome pushed by those who stand to profit.

I never dreamed that my discovery four decades ago would lead to such a profit-driven public health disaster. The medical community must confront reality and stop the inappropriate use of P.S.A. screening. Doing so would save billions of dollars and rescue millions of men from unnecessary, debilitating treatments.

Richard J. Ablin is a research professor of immunobiology and pathology at the University of Arizona College of Medicine and the president of the Robert Benjamin Ablin Foundation for Cancer Research.

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yaah said:

Part of 88305 is time commitment and tech time though. Breast biopsies are not entirely comparable because there is a mass and usually there are 2-3 cores sampled directly from it, which can all be put in one block. Prostate cores to be optimally examined need to be no more than 2 per block, and numerous studies have shown that a 12 core biopsy series is much better than 6 at detecting clinically important cancers (as well as clinically unimportant cancers!). I agree the 12 separate specimen thing is unnecessary, but 6 sites (two cores per site) is more informative - they do adjust their treatment based on location. CPT coding has been adjusted recently to provide a separate code for extensive biopsy series.

Now, this is an interesting article, but it is missing one important factor - lawsuits. There was a recent lawsuit I read about where the family physician had a discussion with a patient about doing PSA as a supplement to a normal DRE to screen for cancer. They discussed benefits, risks. Patient decided not to get it. Two years later patient had a PSA from another physician, it was elevated and he had cancer. So he sued the family doc for delayed diagnosis. This happens a lot. It is getting to the point where if patients do wish to decline PSA testing they may have to sign a waiver stating they understand the risks. And despite all the recommendations, many patients just want their cancer treated because they would rather deal with the potential side effects than the potential progression. A lot of this is education of the patient by physicians but a lot of it is also the problem that it is difficult to apply wide trends to one individual patient.

Prostate cancer is definitely overtreated but where do you draw the line? There is no real good evidence now as to where to draw that line. Do you only treat 4+3 and higher? What it seems like is happening is that there will be an increasing array of tests (molecular and otherwise) that attempt to stratify risk in either the screening populations or patients already diagnosed. This may end up adding even more to the cost of care even if it reduces some surgeries.

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