October 24, 2011

Uproar Over PSA Testing: Would I Have Been Better Served If I'd NOT Had the Test OR the Operation?

I've been following with interest the fallout from a federal task force conclusion that most men should not routinely get the PSA blood test for evidence of prostate cancer. I got the test back in 1994 and had my prostate surgically removed in 1995. A post-operative PSA test showed that cancer cells remained, and I've had the test every six months since then.

Now, the U.S. Preventive Services Task Force has concluded that the exam does not save lives and may even lead to harm for 20-30% of men. (These PSA recommendations are proposed and still have to go through a comment and review procedure.)

The task force stirred up similar controversy in 2009 when it recommended against routine mammograms for women under 50, and suggested screening at two-year intervals after that age. When a firestorm of protest erupted, the recommendation was withdrawn.

The 16-member task force -- which reports to the Department of Health and Human Services -- was established to perform an evidence-based assessment of preventive medical care. Its recommendations could affect what services Medicare and private insurers will cover. And under last year's health care reform law, their findings carry additional weight.

The PSA issue is part of a bigger, growing debate about our overuse of tests, drugs and procedures. Does this trend toward excess (which seems part of our culture) needlessly drive up health care costs and expose patients to risks? Does it help explain why U.S. healthcare is the world's most expensive, but hardly the best?

Prostate Cancer and PSA
Prostate cancer strikes more than 218,000 men in America each year. About 28,000 die from it -- the most common cancer among men, and the second leading cancer killer. But it often grows slowly, so most men with prostate cancer die from something else.

Although this cancer can be detected by a physical examination, the PSA blood test has become the most common diagnostic tool. Still, it’s not clear what exact PSA level truly indicates the presence of cancer. As a result, biopsies are frequent, and the cancer is often detected very early.

And when cancer is detected, it's not clear what should be done about it. The options include "watchful waiting,” surgery, radiation, and hormone treatments. Those last three options are likely to result in varying degrees of impotence and/or incontinence.

PSA, Prostate Cancer and Me
I began getting PSA tests every six months when I turned 60. Five years later – in 1994 -- my PSA number escalated. A biopsy showed the presence of cancer at state B-1 (A is so miniscule it often goes undetected; C and D cancers have probably spread beyond the prostate).

After consulting with my urologist and researching the issue myself, I narrowed my choices to surgery or watchful waiting. When confronted with a problem with choices "do nothing" or "do something," I’ve invariably opted for the latter, but I now wonder about that preference in this case. My prostate was removed in January 1995, the month after I retired. (I kidded my pal Bill Beltz, then president of BNA, that I scheduled the procedure so bills would go to Medicare, not BNA.)

My urologist said the biopsy on the removed prostate clearly reconfirmed the rightness of our decision to operate. He also said there wasn’t always such definite clarity in these cases.

Because my regular PSA tests through the years had shown such slow increases -- and as I dealt with Parkinson’s and other health issues -- I'd practically forgotten about the prostate cancer. But at my regular checkup last month, the PSA number jumped to 9.4, more than double the 4.04 reading six months earlier! My urologist urged me not to panic; we'll see where the number is at the March checkup. Hormone treatment may be down the road.

Bottom Line: Would I have been better off without the PSA test (or with "watchful waiting" instead of surgery)?
I've always told my doctors it’s the quality – not length -- of life that matters to me. I'm not interested in sticking around to get my 100th birthday greetings from Willard Scott if I'm unhappy and miserable.

For me, good sex has always been up there on my quality-of-life scorecard (though – sigh -- much less so in the last few years). For my family’s sake, I'll rein in my usual TMI tendency by just saying that the prostate operation did have its negative consequences in this area.

When I look at the 16 years of slow growth in my PSA number since the operation, I have to wonder: would I have enjoyed life more if I’d never been tested (and operated on)? I suspect I might have had a higher quality of life in the earlier years, and a lower quality of life later. And – oh, yeah – maybe an earlier death.

Weighing alternatives like these is a very personal matter. And the basic issue isn't whether or not to get the PSA test; it's choosing an option when the results are in. I'm turned off by all the "Obama death panel" blather. The government should be exploring how to control our ever-escalating health care costs by giving us the best information about drugs, tests, and procedures… keeping in mind that “more” may not be better, and that “more” might also be harmful.

But here’s where it gets tricky, and I get uncertain. Should we:
  • Let the government collect and provide the best information, but leave it to the doctor and patient to make the decision? This option probably wouldn't cut costs. Doctors are usually reluctant to recommend against a test or procedure. Many patients don't try to inform themselves or take an active role in managing their own health care. And families typically recommend the "do something" option.
  • Let the government and/or insurance companies play a more aggressive role by declining reimbursement for tests or procedures if evidence shows they don't do much good or even cause harm? The current PSA flap reflects the concern many people have that the task force's recommendations are moving us in this direction.
It’s a dilemma. I want to play an active role in these decisions, with my doctors. But I also think my doctor and I – like most other patients and professionals -- will tend to choose options that create needless cost and even unexpected harm.

What do you think? Are there other options? I’d love to hear from you.

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