An Intuitive Reason for Rising Health Care Costs

I got something in my e-mail this morning. It\’s a press release aimed at helping with prostate cancer awareness month, and is supported by Lance Armstrong\’s foundation.

SURVEY SHOWS AT-RISK MEN LACKING IN PROSTATE CANCER KNOWLEDGE

SUNNYVALE, CALIF.,– September 9, 2009 – Prostate cancer remains one of the most commonly diagnosed cancers in the United States. In fact, one in six men will develop prostate cancer. It is also the second-leading cause of cancer death in the United States. But a recent survey suggests that many men at risk for the cancer still aren’t aware of all available treatment options. The survey, conducted late last year, reveals that nearly 50% of men aged 40 and older are not aware of the most common approach to surgery for prostate cancer — robotic-assisted surgery to remove the prostate. “I had to do my own research and then self-admit myself to the [hospital],” says surgery patient Tim Propheter. “…. Most people are just told … ‘Sorry, you have to have surgery, and we\’ll set you up for such and such day,’ and they don\’t know any better until they run into someone like me,” he says. This lack of information persists despite the fact that prostate cancer treatment has changed dramatically in the last decade. For example, surgery — which remains the gold standard treatment for localized prostate cancer — has become much less invasive. According to the American Urologic Association, the major benefit of prostatectomy, or prostate removal, is a potential “cancer cure” in patients with localized or early stage cancer.

Guess who the press release was from? Guess who sponsored the survey? The following was at the bottom of the email:

About the survey

Data was collected from 1000 self-selected adult healthcare information seekers through an online panel available through Ztelligence.com, using an survey questionnaire. Fifty-four percent of those were male and 46 percent were female. The results reflect only the opinions of the healthcare seekers who chose to participate.

About Intuitive Surgical, Inc.

The survey was conducted by Intuitive Surgical, Inc. (NASDAQ: ISRG), the manufacturer of the da Vinci Surgical System, the world’s only commercially available system designed to allow physicians to provide a minimally invasive option for complex surgeries. Intuitive Surgical, headquartered in Sunnyvale, California, is the global technology leader in robotic-assisted, minimally invasive surgery (MIS). Intuitive Surgical develops, manufactures and markets robotic technologies designed to improve clinical outcomes and help patients return more quickly to active and productive lives. The company’s mission is to extend the benefits of minimally invasive surgery to the broadest possible base of patients. Intuitive Surgical — Taking surgery beyond the limits of the human hand.™

Imagine that. A survey done by company that sells the da Vinci robotic surgical equipment shows that men have tragically no knowledge of the da Vinci robotic prostate surgery!

So let\’s see what the evidence shows:

  • Prostate cancer occurs in 186,000 men each year and kills nearly 29,000.
  • In a well-known autopsy survey, over 1/3 of men over 80 were found to have cancer present in their prostate without evidence of significant disease.  It is not clear how many of these men will progress to overt cancer, but it is very clear that this is the vast minority.
  • PSA Testing (the blood test for prostate cancer screening) is by far the largest source of surgical candidates.  It is a controversial test, having a high rate of false positives and an unproven record of significant benefit.

From the reference uptodate.com:

The European Randomized Study of Screening for Prostate Cancer (ERSPC) reported a small absolute survival benefit with PSA screening after nine years of follow-up; however, 48 additional patients would need aggressive treatment to prevent one prostate cancer death. Although the report did not address quality of life outcomes, considerable data show the potential harms from aggressive treatments. Further sustaining the uncertainty surrounding screening, a report from the large United States trial, the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, published concurrently with the European trial, found no benefit for annual PSA and digital rectal examination (DRE) screening after seven to ten years of follow-up. The crux of this screening dilemma was aptly stated by the urologist Willet Whitmore, who asked \”is cure possible in those for whom it is necessary, and is cure necessary in those for whom it is possible?\”

The most important line in this is at the end of the first sentence, stating that 48 patients would need aggressive treatment (including prostatectomy) to prevent one prostate cancer death.  So how much does \”aggressive treatment to prevent cancer death\” cost?

From the Journal of Clinical Oncology:

For patients in the treatment-received analysis, the average costs were significantly different; $14,048 (95% confidence interval [CI], $13,765 to $14,330) for radiation therapy and $17,226 (95% CI, $16,891 to $17,560) for radical prostatectomy (P < .001). The average costs for patients in the intent-to-treat analysis were also significantly less for radiation therapy patients ($14,048; 95% CI, $13,765 to $14,330) than for those who underwent radical prostatectomy ($17,516; 95% CI, $17,195 to $17,837; P < .001).

note: it was very hard to find numbers here.  This is actually from Medicare claims from 1992 and 1993, so it is a huge underestimate from today\’s numbers.

Which means that based on the 1992 numbers, you would spend $672,000 to save one life using radiation therapy and $1,084,000 if you used surgery.  This does not take into account the consequences of surgery for the men who underwent the surgery.

What about robotic surgery?  In a comparison of the cost of open prostatectomy to robot-assisted surgery, the cost is even higher.

Cost was the one area in which the older open surgery was the clear winner: Open radical prostatectomy costs $487 less a case than non-robotic laparoscopy and $1,726 less than robot-assisted prostatectomy.

According to the review, \”Shorter operative time and decreased hospital stays associated with the robotic procedure did not make up for the cost of the additional equipment expenditure.\” Estimated costs of the robotic system to a provider run about $1.2 million a year, with maintenance costs of $120,000 a year and one-time costs of $1,500 a case.

To summarize:

  • Prostate cancer screening is controversial, as it fails to differentiate between the minority of men who would die from the disease from the majority who would simply die with it.
  • PSA Testing as greatly increased the number of men diagnosed with early stage cancers.
  • Prostate cancer surgery or radiation therapy is recommended for men who have early stage cancers.
  • Aggressive prostate cancer treatment has to be done 48 times to save one life.
  • The most expensive treatment for prostate cancer is prostatectomy, or removal of the prostate.
  • The robotic form of the surgery is a higher-cost procedure by a significant amount.

So, an expensive form of surgery that may not be appropriate is done on a group of men identified on a very unreliable test yielding a very small number of lives saved and a lot of men who then have to deal with the physical consequences of the surgery.  Why in the world is this being promoted at all?

Money.  Here\’s the homepage of one of our local hospitals.  They have aggressively marketed da Vinci surgery on television, billboards, and the radio.

Why do you think they would pay as much money as they do for this device?  It\’s good business?  Not so fast.  Dr. Paul Levy stated back in 2007 about this very procedure:

Here you have it folks — the problem facing every hospital, and especially every academic medical center. Do I spend over $1 million on a machine that has no proven incremental value for patients, so that our doctors can become adept at using it and stay up-to-date with the \”state of the art\”, so that I can then spend more money marketing it, and so that I can protect profitable market share against similar moves by my competitors?

No, hospitals are employing this just to keep pace.  The real winner in this is Intuitive Surgical, Inc., who has been a darling of Wall Street, beating estimates in earnings with a Q2 net profit of $62.4 Million.

Why is the cost of healthcare going up while physician reimbursement goes down and hospitals go out of business?

It\’s Intuitive.

God Bless America!

81 thoughts on “An Intuitive Reason for Rising Health Care Costs”

  1. If you read this as an “Anti PSA post,” you miss the point. PSA is the best we have and I do order them, but I have no illusion that it is a good test. I hate PSA because we have no better and so I have to subject a lot of men to the diagnosis of possible prostate cancer and put them through painful and disabling surgery without a clear idea that I am actually helping them. I hate the test as a clinician seeing men all day long and not wanting them to suffer without real benefit. I hate the test because I have to rely on it to tell me what it cant: who will get invasive prostate CA and die from it and who will simply die with it.
    This whole subject gives very good reason to be cynical. OF COURSE the urologists will think PSA testing is good, for the same reason cardiologists like stents and the surgeons like the robotic surgery. It gives them their main source of revenue. I don’t think this guides all of their opinions, but I can say that if I were a urologist, I would be hard-pressed to bite the hand that feeds me.

    I understand why you feel like you do, but I am pro-science, not anti-PSA. I am pro-patient, pro-male, and against sending the healthcare dollars that are not going to primary care to the shareholders of Intuitive Surgical, Inc. You see your own story, and I see the story of the thousands of men I have cared for and of my father who was diagnosed with prostate CA at age 75.

    PSA is a lousy test, and there are many who wonder if there is not a large lobby of people trying to keep it around because the lousiness is a great business model.

  2. If you read this as an “Anti PSA post,” you miss the point. PSA is the best we have and I do order them, but I have no illusion that it is a good test. I hate PSA because we have no better and so I have to subject a lot of men to the diagnosis of possible prostate cancer and put them through painful and disabling surgery without a clear idea that I am actually helping them. I hate the test as a clinician seeing men all day long and not wanting them to suffer without real benefit. I hate the test because I have to rely on it to tell me what it cant: who will get invasive prostate CA and die from it and who will simply die with it.
    This whole subject gives very good reason to be cynical. OF COURSE the urologists will think PSA testing is good, for the same reason cardiologists like stents and the surgeons like the robotic surgery. It gives them their main source of revenue. I don’t think this guides all of their opinions, but I can say that if I were a urologist, I would be hard-pressed to bite the hand that feeds me.

    I understand why you feel like you do, but I am pro-science, not anti-PSA. I am pro-patient, pro-male, and against sending the healthcare dollars that are not going to primary care to the shareholders of Intuitive Surgical, Inc. You see your own story, and I see the story of the thousands of men I have cared for and of my father who was diagnosed with prostate CA at age 75.

    PSA is a lousy test, and there are many who wonder if there is not a large lobby of people trying to keep it around because the lousiness is a great business model.

  3. I see I was foaming at the mouth but I forgot a couple of important things. If there is sufficient reason to suspect prostate cancer, e.g. based on a PSA, digitial rectal exam, and/or other symptoms, the next key step is a biopsy. This is an uncomfortable procedure with little in the way of side effects and will allow a pathologist to look at samples of cells from your prostate. Then such things as your gleason score can be obtained and then and only then can possible approaches be explored. One approach of growing application is active surveillance, for those whose cancers are fortunately not too agressive, where the state of your cancer is monitored in order to minimize the chances of overtreatment while maximizing the chances of detecting changes to a more agressive state. The problem is that if the cancer becomes aggressive enough to leave the prostate, you will be fighting metastatic prostate cancer for the rest of your life. Scary isn’t it. Many men would rather not think about this, stick their heads in the sand and avoid PSA testing, and play Russian Roulette. Don’t be scared of getting a PSA test and don’t be scared into over treatment should you be unfortunate enough to have prostate cancer. Many cases will be indolent and not effect your life or death, some cases will cause a horrible death. Modern techniques can detect the problem, diagnose and predict with unfortunatley some uncertainty, but lead you to make a decision that will effect the rest of your life. Take control, don’t be a statistic of massive misleading public health statistics. You are an individual, don’t be a statistic.

  4. I see I was foaming at the mouth but I forgot a couple of important things. If there is sufficient reason to suspect prostate cancer, e.g. based on a PSA, digitial rectal exam, and/or other symptoms, the next key step is a biopsy. This is an uncomfortable procedure with little in the way of side effects and will allow a pathologist to look at samples of cells from your prostate. Then such things as your gleason score can be obtained and then and only then can possible approaches be explored. One approach of growing application is active surveillance, for those whose cancers are fortunately not too agressive, where the state of your cancer is monitored in order to minimize the chances of overtreatment while maximizing the chances of detecting changes to a more agressive state. The problem is that if the cancer becomes aggressive enough to leave the prostate, you will be fighting metastatic prostate cancer for the rest of your life. Scary isn’t it. Many men would rather not think about this, stick their heads in the sand and avoid PSA testing, and play Russian Roulette. Don’t be scared of getting a PSA test and don’t be scared into over treatment should you be unfortunate enough to have prostate cancer. Many cases will be indolent and not effect your life or death, some cases will cause a horrible death. Modern techniques can detect the problem, diagnose and predict with unfortunatley some uncertainty, but lead you to make a decision that will effect the rest of your life. Take control, don’t be a statistic of massive misleading public health statistics. You are an individual, don’t be a statistic.

  5. this post is so on the mark.I think I am going to use this post as a jumping off point for a discussion on prostate cancer with medical students. Thanks for putting this all together.

  6. this post is so on the mark.I think I am going to use this post as a jumping off point for a discussion on prostate cancer with medical students. Thanks for putting this all together.

  7. Some would call this “rationing healthcare”. Yes, it is rationing based on good common sense and “evidence based” logic as well. Once we realize that no one in this country can get everything that they want in healthcare, whenever they want it, from whoever they choose without it costing them and others, then we will realize the need for some logical healthcare reform.

  8. Some would call this “rationing healthcare”. Yes, it is rationing based on good common sense and “evidence based” logic as well. Once we realize that no one in this country can get everything that they want in healthcare, whenever they want it, from whoever they choose without it costing them and others, then we will realize the need for some logical healthcare reform.

  9. I hate to read these anti PSA blogs so early in the morning. But wait, if I never had my PSA test in 1997 I probably wouldn’t have to worry about what I read in the morning — I’d probably be dead by now from the ravages of prostate cancer (God forbid). Your article is SO one sided. Men, and the women who love them, get the facts about the modern approach to prostate cancer. PSA testing is simply an attempt to get information about about the state of one’s prostate, along with Digital Rectal Exam. Both can raise red flags but NO treatment should be based on them. If there is an indication of a problem (which could be life threatening) there are now very sophisticated and nuanced approaches to trying to get reasonable estimate of your likelihood of incurable invasive and horrible prostate cancer versus indolent prostate cancer which remains in the prostate. You have options — active surveillance, surgery, radiation etc, that can greatly benefit your life and not make you one of the ten’s of thousands of men suffering from and dying of prostate cancer each year. But no, the above author says, it costs society too much to try to save you. Rather than by the above one sided approach, check out the expert recommendations of the American Urological Association and the National Comprehensive Cancer Network. In the words of a leading urologist:
    : “If you are a healthy man with a more than 10- to 15-year life expectancy and you don’t want to die from prostate cancer, you should have PSA testing; intelligent testing and treatment could save your life,” said Dr. Patrick C. Walsh, university distinguished service professor of urology at Johns Hopkins.

  10. I hate to read these anti PSA blogs so early in the morning. But wait, if I never had my PSA test in 1997 I probably wouldn’t have to worry about what I read in the morning — I’d probably be dead by now from the ravages of prostate cancer (God forbid). Your article is SO one sided. Men, and the women who love them, get the facts about the modern approach to prostate cancer. PSA testing is simply an attempt to get information about about the state of one’s prostate, along with Digital Rectal Exam. Both can raise red flags but NO treatment should be based on them. If there is an indication of a problem (which could be life threatening) there are now very sophisticated and nuanced approaches to trying to get reasonable estimate of your likelihood of incurable invasive and horrible prostate cancer versus indolent prostate cancer which remains in the prostate. You have options — active surveillance, surgery, radiation etc, that can greatly benefit your life and not make you one of the ten’s of thousands of men suffering from and dying of prostate cancer each year. But no, the above author says, it costs society too much to try to save you. Rather than by the above one sided approach, check out the expert recommendations of the American Urological Association and the National Comprehensive Cancer Network. In the words of a leading urologist:
    : “If you are a healthy man with a more than 10- to 15-year life expectancy and you don’t want to die from prostate cancer, you should have PSA testing; intelligent testing and treatment could save your life,” said Dr. Patrick C. Walsh, university distinguished service professor of urology at Johns Hopkins.

  11. We docs do know about the biopsy and Gleason score – that is accounted for in the “48 patients receiving aggressive therapy to save 1.” That statistic alone means that you are grossly understating the “unfortunate uncertainty.” You just never hear about the men who are impotent or in chronic pain because of prostatectomy.

  12. We docs do know about the biopsy and Gleason score – that is accounted for in the “48 patients receiving aggressive therapy to save 1.” That statistic alone means that you are grossly understating the “unfortunate uncertainty.” You just never hear about the men who are impotent or in chronic pain because of prostatectomy.

  13. I am absolutely hearhearing you on this Dr. Rob. (can you hear the hearhear?) Treating medicine like any other business — with point-of-sale marketing, TV spots, “five out of six experts agree”, etc. — is an awful idea, bad for individual health and deadly where cost is concerned. The practice of pharmaceutical and other medical technology companies sponsoring their own scientific or faux-scientific research indicates, to me, that the profit motive is either spreading to researchers and academics who should rightly be insulated from it, or replacing them outright.
    And this is going to sound paranoid, but Lee sounds like a plant to me — I had this long conversation on my blog with this woman who felt like the reason young people were uninsured was because they were too cheap to buy a new insurance industry product called GradMed, catastrophic insurance for the first years after college. After a while, I got the feeling that she knew a lot about GradMed — and then I looked into it and realized it’s a horribly exploitative, high-profit no-coverage profit-taking scheme that is just in its earliest stages. I asked her how she learned so much about it and she just disappeared.

    Anyway, that’s what occurs to me now when I see someone come in and explain something like biopsy to an experienced general practitioner, and then put half their post in the imperative mood.

    (PS: almost forgot to say that all men, and the women who love them, should eat Skippy ™ brand peanut butter! Five out of ten doctorologists agree that it is the Skippiest!)

  14. I am absolutely hearhearing you on this Dr. Rob. (can you hear the hearhear?) Treating medicine like any other business — with point-of-sale marketing, TV spots, “five out of six experts agree”, etc. — is an awful idea, bad for individual health and deadly where cost is concerned. The practice of pharmaceutical and other medical technology companies sponsoring their own scientific or faux-scientific research indicates, to me, that the profit motive is either spreading to researchers and academics who should rightly be insulated from it, or replacing them outright.
    And this is going to sound paranoid, but Lee sounds like a plant to me — I had this long conversation on my blog with this woman who felt like the reason young people were uninsured was because they were too cheap to buy a new insurance industry product called GradMed, catastrophic insurance for the first years after college. After a while, I got the feeling that she knew a lot about GradMed — and then I looked into it and realized it’s a horribly exploitative, high-profit no-coverage profit-taking scheme that is just in its earliest stages. I asked her how she learned so much about it and she just disappeared.

    Anyway, that’s what occurs to me now when I see someone come in and explain something like biopsy to an experienced general practitioner, and then put half their post in the imperative mood.

    (PS: almost forgot to say that all men, and the women who love them, should eat Skippy ™ brand peanut butter! Five out of ten doctorologists agree that it is the Skippiest!)

  15. I actually wondered about that. His pitch sounds like a pitch. The problem is, in this setting it actually weakens the argument. He is arguing anecdotal information against science. It shows how weak the argument for PSA testing really is.

  16. I actually wondered about that. His pitch sounds like a pitch. The problem is, in this setting it actually weakens the argument. He is arguing anecdotal information against science. It shows how weak the argument for PSA testing really is.

  17. Glad I’m not just hearing voices. It seems like a common weakness, though, of these types of people to come in through google and not spend a great deal of time figuring out their current context before they post.

  18. Glad I’m not just hearing voices. It seems like a common weakness, though, of these types of people to come in through google and not spend a great deal of time figuring out their current context before they post.

  19. Well, as the wife of someone with a high Gleason score cancer that was spotted when he was 50, I’m all about the treatment where warranted.
    We did have an option for robotic, but that wasn’t feasible due to a prior surgery. Instead, he had the same surgeon in a different facility performing laparoscopic with a backup of open surgery.

    PSA’s as flawed a number as TSH is for thyroid function, but at least it’s something that can be measured. So many cancers don’t offer a readily-available sign even for some instances.

  20. Well, as the wife of someone with a high Gleason score cancer that was spotted when he was 50, I’m all about the treatment where warranted.
    We did have an option for robotic, but that wasn’t feasible due to a prior surgery. Instead, he had the same surgeon in a different facility performing laparoscopic with a backup of open surgery.

    PSA’s as flawed a number as TSH is for thyroid function, but at least it’s something that can be measured. So many cancers don’t offer a readily-available sign even for some instances.

  21. A question the possible shill raised upstream: is it actually the case (as Lee implied) that some patients are going from elevated PSA directly into major surgery? I’d expect that a biopsy would be the norm.

  22. A question the possible shill raised upstream: is it actually the case (as Lee implied) that some patients are going from elevated PSA directly into major surgery? I’d expect that a biopsy would be the norm.

  23. Wow you guys do go on. I am of course a plant, an anecdote, because I believe PSA testing saved my life, or at least significantly aided my leading a relatively happy life for the past 13 years. Yes my erections aren’t what they used to be. But my wife and I discussed that before the surgery and we agreed it was better for me to be around than to continue on as a stud. Seriously though we all know that the so called studies aren’t science. The trials in the recent NEJM studies were hopelessly contaminated by lack of controls as well as being out of date. The Europeans have already upped their estimates. And as far as statistics, I’m not up on the latest but nomgrams such as the Partin tables were extremely helpful in helping me chart my course and in my case chose a radical prostetectomy. You see the scientific data clearly showed that someone with my PSA, gleason score, etc had a 60 % chance of still having an organ confined disease. I chose not to wait for the odds to get worse by waiting any longer. The massive studies, so far as I could tell showed no data about Gleason scores so we have no way of knowing what sort of approach was utilized following the PSA readings. Scientifically and logically this tells me to chose the proper practice. Finally, science is all about anecdotes so what should be studied are the successful cases, men who were able to beat or at least slow down their prostate cancer. See what went right, because fortunately there are more and more of us and that’s the reason I waste my time on this bloging — just in case there is even one man out there who will not forgo PSA testing based on reading my comments. You see, in my religion we believe saving a single life is like saving a whole world because each individual is a unique being in the image of God. Unforunately the mass public health advocates see it all as dollars and cents — how much it cost to save my life. I in turn wish to pass it on — and help save another life through common sense — find out what you have and decide what to do. Ignoring possible cancer is not a treatment its Russian Roulette — and even if you only have 1 chance in lets say 10 of killing yourself, why take that chance when PSA testing and credible medical advice can improve things further. I do believe it’s important to have a healthy mistrust of MDs. Clearly they are overpaid, and medical school criteria make little sense, turning away lots of good potential MDs while accepting students who know “how to play the game”. But I unfortunately apriori need to extend that mistrust to Dr. Bob, who I don’t know, while I have met urologists that I would and have trusted my life and well being to.

  24. Wow you guys do go on. I am of course a plant, an anecdote, because I believe PSA testing saved my life, or at least significantly aided my leading a relatively happy life for the past 13 years. Yes my erections aren’t what they used to be. But my wife and I discussed that before the surgery and we agreed it was better for me to be around than to continue on as a stud. Seriously though we all know that the so called studies aren’t science. The trials in the recent NEJM studies were hopelessly contaminated by lack of controls as well as being out of date. The Europeans have already upped their estimates. And as far as statistics, I’m not up on the latest but nomgrams such as the Partin tables were extremely helpful in helping me chart my course and in my case chose a radical prostetectomy. You see the scientific data clearly showed that someone with my PSA, gleason score, etc had a 60 % chance of still having an organ confined disease. I chose not to wait for the odds to get worse by waiting any longer. The massive studies, so far as I could tell showed no data about Gleason scores so we have no way of knowing what sort of approach was utilized following the PSA readings. Scientifically and logically this tells me to chose the proper practice. Finally, science is all about anecdotes so what should be studied are the successful cases, men who were able to beat or at least slow down their prostate cancer. See what went right, because fortunately there are more and more of us and that’s the reason I waste my time on this bloging — just in case there is even one man out there who will not forgo PSA testing based on reading my comments. You see, in my religion we believe saving a single life is like saving a whole world because each individual is a unique being in the image of God. Unforunately the mass public health advocates see it all as dollars and cents — how much it cost to save my life. I in turn wish to pass it on — and help save another life through common sense — find out what you have and decide what to do. Ignoring possible cancer is not a treatment its Russian Roulette — and even if you only have 1 chance in lets say 10 of killing yourself, why take that chance when PSA testing and credible medical advice can improve things further. I do believe it’s important to have a healthy mistrust of MDs. Clearly they are overpaid, and medical school criteria make little sense, turning away lots of good potential MDs while accepting students who know “how to play the game”. But I unfortunately apriori need to extend that mistrust to Dr. Bob, who I don’t know, while I have met urologists that I would and have trusted my life and well being to.

  25. Okay, time to get serious. There is an opportunity to both continue to save useless lives such as mine while reducing costs. It may mean that you have to share your patients with urologists but perhaps they will give you a “finders fee”. The answer may be active surveillance. When I was diagnosed the alternative to treatment was “watchful waiting” but I could never find an explanation of what I was waiting for and didn’t want to wait for cancer to invade my body. Now there are protocols being established, and data has been published, to show that that one can, in carefully managed cases, get the best of both worlds, saving lives and $$. i turn your attention to an editorial in the current online edition of the Journal of Clinical Oncology:http://jco.ascopubs.org/cgi/reprint/JCO.2009.24.4533v1
    Perhaps you can read it over, and the accompanying article (which I don’t seem to have access to on the web) and let us know what you think. But it all begins with three little letters: PSA.

  26. Okay, time to get serious. There is an opportunity to both continue to save useless lives such as mine while reducing costs. It may mean that you have to share your patients with urologists but perhaps they will give you a “finders fee”. The answer may be active surveillance. When I was diagnosed the alternative to treatment was “watchful waiting” but I could never find an explanation of what I was waiting for and didn’t want to wait for cancer to invade my body. Now there are protocols being established, and data has been published, to show that that one can, in carefully managed cases, get the best of both worlds, saving lives and $$. i turn your attention to an editorial in the current online edition of the Journal of Clinical Oncology:http://jco.ascopubs.org/cgi/reprint/JCO.2009.24.4533v1
    Perhaps you can read it over, and the accompanying article (which I don’t seem to have access to on the web) and let us know what you think. But it all begins with three little letters: PSA.

  27. OK. I am wrong. PSA testing should start at age 10. We should do it in women too…just in case.
    Seriously, you folks have missed the forest for the trees. This post is not meant to bash PSA testing; it is meant to point out that corporate greed is what is driving the cost of medicine through the roof. Procedures like the da Vinci surgical procedures are somehow being paid for (not just for prostatectomy). The fact is, da Vinci manufacturers could care less about the validity of PSA testing – they are going to support it to the hilt because it is an incredible business model for them.

    This is not a black and white area (either way). I do order PSA for men between 50 and 65, but do so with a lot of discomfort. I am not some academic arguing this. I only used PSA because it was what came up and the evidence for the procedure they were pushing is not real strong. The major scientific bodies don’t have it in for men and their prostates – they really feel that men are being harmed in the name of catching cancer early. Harming people is not something we physicians like to do.

    Regardless, the system is rife with examples of huge amounts of spending on very questionable procedures (cardiac stenting, liver transplantation in alcoholics, alzheimer patients sent to the ICU and kept alive “at all costs”).

    We are not alternative medicine. We don’t rely on testimonials when the data gets scant. We rely on the best scientific data out there, and the current evidence raises lots of questions about things we are spending lots of money on. I could have just as easily given Boston Scientific or Medtronic as examples of companies that push profitable procedures that have little scientific backing.

    This is the problem with this debate on healthcare. People get all huffy and emotional about their pet areas and feel like someone is out to get them. I really am not. I really don’t want the men I care for to get prostate cancer. Really. But we have to control cost, and the best place to look is where the science says we are wrong to do what we do. PSA testing is in the grey zone, so I don’t think it is the first on the chopping block, but something has to give or we are going to have no money left. Come on people! Keep your eye on the real issue!!

  28. OK. I am wrong. PSA testing should start at age 10. We should do it in women too…just in case.
    Seriously, you folks have missed the forest for the trees. This post is not meant to bash PSA testing; it is meant to point out that corporate greed is what is driving the cost of medicine through the roof. Procedures like the da Vinci surgical procedures are somehow being paid for (not just for prostatectomy). The fact is, da Vinci manufacturers could care less about the validity of PSA testing – they are going to support it to the hilt because it is an incredible business model for them.

    This is not a black and white area (either way). I do order PSA for men between 50 and 65, but do so with a lot of discomfort. I am not some academic arguing this. I only used PSA because it was what came up and the evidence for the procedure they were pushing is not real strong. The major scientific bodies don’t have it in for men and their prostates – they really feel that men are being harmed in the name of catching cancer early. Harming people is not something we physicians like to do.

    Regardless, the system is rife with examples of huge amounts of spending on very questionable procedures (cardiac stenting, liver transplantation in alcoholics, alzheimer patients sent to the ICU and kept alive “at all costs”).

    We are not alternative medicine. We don’t rely on testimonials when the data gets scant. We rely on the best scientific data out there, and the current evidence raises lots of questions about things we are spending lots of money on. I could have just as easily given Boston Scientific or Medtronic as examples of companies that push profitable procedures that have little scientific backing.

    This is the problem with this debate on healthcare. People get all huffy and emotional about their pet areas and feel like someone is out to get them. I really am not. I really don’t want the men I care for to get prostate cancer. Really. But we have to control cost, and the best place to look is where the science says we are wrong to do what we do. PSA testing is in the grey zone, so I don’t think it is the first on the chopping block, but something has to give or we are going to have no money left. Come on people! Keep your eye on the real issue!!

  29. Who is doctor Bob?
    If you say “science is all about anecdotes” you might just as well be arguing for alternative medical therapies that have been totally discredited. I don’t practice woo, I practice applied science.

    I am also one who believes that we are made in the image of God. I also believe that the body is a temple and we should not be setting up tables in it and cashing in on the fears of the vulnerable. That is what Christ abhorred when he cleared the temple. He also commanded that we be stewards of what we have been given. I see the cost of care going up and people being without insurance. My payments have gone down and Intuitive Surgical’s profits have soared. People are dying because of the poor spending we are doing.

    Lee, you really are seeing things in a very narrow view. Everyone wants everything done all the time. We can’t do that. You know that, but you just don’t want to give up your pet area. I am sorry that this seemed like I attacked PSA. I had no intent to do so. Don’t you see that there is lots of waste? Do you really think we can continue to spend like we are doing now??

  30. Who is doctor Bob?
    If you say “science is all about anecdotes” you might just as well be arguing for alternative medical therapies that have been totally discredited. I don’t practice woo, I practice applied science.

    I am also one who believes that we are made in the image of God. I also believe that the body is a temple and we should not be setting up tables in it and cashing in on the fears of the vulnerable. That is what Christ abhorred when he cleared the temple. He also commanded that we be stewards of what we have been given. I see the cost of care going up and people being without insurance. My payments have gone down and Intuitive Surgical’s profits have soared. People are dying because of the poor spending we are doing.

    Lee, you really are seeing things in a very narrow view. Everyone wants everything done all the time. We can’t do that. You know that, but you just don’t want to give up your pet area. I am sorry that this seemed like I attacked PSA. I had no intent to do so. Don’t you see that there is lots of waste? Do you really think we can continue to spend like we are doing now??

  31. I agree with all you said (except for the TSH comment – TSH is actually way more sensitive and accurate than PSA). I would have tested your husband’s PSA and would have recommended surgery for the high score. It’s the best we have now. It’s lousy, because lots of men who will not die from their cancer are being put through suffering; but it’s the best we have. I don’t have to like it.

  32. I agree with all you said (except for the TSH comment – TSH is actually way more sensitive and accurate than PSA). I would have tested your husband’s PSA and would have recommended surgery for the high score. It’s the best we have now. It’s lousy, because lots of men who will not die from their cancer are being put through suffering; but it’s the best we have. I don’t have to like it.

  33. What, no comments on active surveillance? I thought that might be the way to go and am interested in your views. Do you recommend that for your patients. By the way, the europeans continue to up the number of men saved by PSA screening, even in an interval as short as 9 years. It’s now up to 31%. Sadly, the American “clinical scientists” don’t seem to have commented on the corruption of their studies by massive PSA testing within the control group. The bottom line for me is that men shouldn’t be frightened away from PSA testing, which will unfortunately be the outcome of many of the current articles, nor should they be frightened into overtreatment. The answer, for me, is education both for potential patients, and for the MDs who treat them. It seems that there isn’t enough of that in either direction. Men give into their fears and avoid testing, MD’s resent their colleagues and fight amongst themselves. Let’s all get together learn and save lives.

  34. What, no comments on active surveillance? I thought that might be the way to go and am interested in your views. Do you recommend that for your patients. By the way, the europeans continue to up the number of men saved by PSA screening, even in an interval as short as 9 years. It’s now up to 31%. Sadly, the American “clinical scientists” don’t seem to have commented on the corruption of their studies by massive PSA testing within the control group. The bottom line for me is that men shouldn’t be frightened away from PSA testing, which will unfortunately be the outcome of many of the current articles, nor should they be frightened into overtreatment. The answer, for me, is education both for potential patients, and for the MDs who treat them. It seems that there isn’t enough of that in either direction. Men give into their fears and avoid testing, MD’s resent their colleagues and fight amongst themselves. Let’s all get together learn and save lives.

  35. So Lee if you would like an anecdotal story from the other side of the fence I have one for you:
    My Father-in-Law got PSA testing and ended up with an elevated PSA. You don’t just ignore a high PSA so he had a prostate biopsy which you say has “little in the way of side effects.” He got one of those “little” side effects. He got bacteria in his blood (a known risk of poking holes in an organ) which caused him to become septic. He developed severe septic shock and had a heart attack. He spent a week in the ICU and barely survived. By the way, the prostate biopsy came back negative. The high PSA that almost lead to his death was a false positive.

    His complications from a prostate biopsy were rare, but the problem is that saved lives from PSA testing are also very rare. When testing helps people very rarely you have to consider how many people are hurt in the process. PSA screening may save some lives but it also leads to some premature deaths. I am aware of no solid evidence that establishes that this massive expensive screening program helps more people than it harms.

    I offer my patients PSA screening, but I don’t just order it for everyone without discussing the associated controversy. I must admit that if I were over 50 I don’t think I would have my PSA tested. It just hasn’t proven to be the good screening tool we all hoped it would be.

    Be careful with angry, emotional arguments claiming people who advise caution about PSA don’t care about your life. I could just as easily say you don’t care about the “useless lives” of men like my father-in-law who have been severely injured or killed by this program. And remember as you evangelize for PSA, remember that for every man you “save” you may also be sending another to an early grave. It’s a bit more complicated than just saying “Let’s all get together learn and save lives!”

    Of course, I’m an MD so you probably should have a “healthy mistrust” of me. I could just be saying all this because I’m jealous that Urologists make more than primary care docs. Seriously Lee, doctors like Dr. Rob spend hours online educating for free because they care, not because they get any money from it. The least you can do is disagree civilly without questioning Rob’s integrity.

  36. So Lee if you would like an anecdotal story from the other side of the fence I have one for you:
    My Father-in-Law got PSA testing and ended up with an elevated PSA. You don’t just ignore a high PSA so he had a prostate biopsy which you say has “little in the way of side effects.” He got one of those “little” side effects. He got bacteria in his blood (a known risk of poking holes in an organ) which caused him to become septic. He developed severe septic shock and had a heart attack. He spent a week in the ICU and barely survived. By the way, the prostate biopsy came back negative. The high PSA that almost lead to his death was a false positive.

    His complications from a prostate biopsy were rare, but the problem is that saved lives from PSA testing are also very rare. When testing helps people very rarely you have to consider how many people are hurt in the process. PSA screening may save some lives but it also leads to some premature deaths. I am aware of no solid evidence that establishes that this massive expensive screening program helps more people than it harms.

    I offer my patients PSA screening, but I don’t just order it for everyone without discussing the associated controversy. I must admit that if I were over 50 I don’t think I would have my PSA tested. It just hasn’t proven to be the good screening tool we all hoped it would be.

    Be careful with angry, emotional arguments claiming people who advise caution about PSA don’t care about your life. I could just as easily say you don’t care about the “useless lives” of men like my father-in-law who have been severely injured or killed by this program. And remember as you evangelize for PSA, remember that for every man you “save” you may also be sending another to an early grave. It’s a bit more complicated than just saying “Let’s all get together learn and save lives!”

    Of course, I’m an MD so you probably should have a “healthy mistrust” of me. I could just be saying all this because I’m jealous that Urologists make more than primary care docs. Seriously Lee, doctors like Dr. Rob spend hours online educating for free because they care, not because they get any money from it. The least you can do is disagree civilly without questioning Rob’s integrity.

  37. This is getting off your point, which was actually really interesting (that being the lobbying of the industry mfrs who stand much to gain by raising health care costs at the expense of the rest of us).
    I’m not a primary care doctor, so I don’t get to see the long-term care of guys who live in pain and other symptoms from aggressive treatment for prostate cancer, and I have to remember that’s your perspective.

    The problem I have with TSH is that it’s only part of the thyroid picture and too many doctors dismiss there being thyroid disease based solely on a TSH number and never check for antibodies, etc. There’s also the issue of the “normal” range. Depending on whose normal you use, mine’s either normal or not [1], but I definitely have clinical thyroid disease (both functional and structural) and do much better on hormones. Sadly, neither of the two endos my HMO has believe me on the functional issue, so I’m paying out-of-pocket for treatment by an out-of-system endo.

    That said, there are fewer false positives in TSH as I understand it.

    [1] But it is above the 95% range of this population survey, so I’d consider that high regardless.

  38. This is getting off your point, which was actually really interesting (that being the lobbying of the industry mfrs who stand much to gain by raising health care costs at the expense of the rest of us).
    I’m not a primary care doctor, so I don’t get to see the long-term care of guys who live in pain and other symptoms from aggressive treatment for prostate cancer, and I have to remember that’s your perspective.

    The problem I have with TSH is that it’s only part of the thyroid picture and too many doctors dismiss there being thyroid disease based solely on a TSH number and never check for antibodies, etc. There’s also the issue of the “normal” range. Depending on whose normal you use, mine’s either normal or not [1], but I definitely have clinical thyroid disease (both functional and structural) and do much better on hormones. Sadly, neither of the two endos my HMO has believe me on the functional issue, so I’m paying out-of-pocket for treatment by an out-of-system endo.

    That said, there are fewer false positives in TSH as I understand it.

    [1] But it is above the 95% range of this population survey, so I’d consider that high regardless.

  39. Doctor D, thank you for your story, and it’s always good to remember that biopsies do have possible side effects. They give Cipro to my husband with his for a reason.
    His aggressive cancer was caught by PSA at age 50, so you might want to re-think testing though. It’s an imperfect test (as Dr. Rob says), but men do die of it.

    I don’t know what the PSA typically costs patients, but one can order one ad hoc for $50 and go to a local lab for a blood draw.

    Breast biopsies also pack a lot of punch — I had visible bruising for weeks and a shadow where the bruise was for about 5 months. Kinda made me worry, given that my grandmother had a breast cancer tumor show up where she’d been hit by a golf ball….

  40. Doctor D, thank you for your story, and it’s always good to remember that biopsies do have possible side effects. They give Cipro to my husband with his for a reason.
    His aggressive cancer was caught by PSA at age 50, so you might want to re-think testing though. It’s an imperfect test (as Dr. Rob says), but men do die of it.

    I don’t know what the PSA typically costs patients, but one can order one ad hoc for $50 and go to a local lab for a blood draw.

    Breast biopsies also pack a lot of punch — I had visible bruising for weeks and a shadow where the bruise was for about 5 months. Kinda made me worry, given that my grandmother had a breast cancer tumor show up where she’d been hit by a golf ball….

  41. Let’s have the numbers on anticipated morbidity of biopsies. A patient should be told all these things, and also numbers specific to the practice he or she is going to. All I can say is I have a small circle of friends, I know about a dozen successful prostatectomies, know problems from biopsies, so maybe my neck of the woods has better urologists but I would recommend going with the flow, and staying away from practices that seem to have too many problems. DCIS is another area of conflicted views — treat or not treat, lumpectomy, margin size, mastectomy, double mastectomy. I say have the tests, see the data, and in collaboration with physicians, getting multiple opinions including major centers, take your best shot — but don’t avoid PSA testing, or mammographies because of these controversies — the truth is out there.

  42. Let’s have the numbers on anticipated morbidity of biopsies. A patient should be told all these things, and also numbers specific to the practice he or she is going to. All I can say is I have a small circle of friends, I know about a dozen successful prostatectomies, know problems from biopsies, so maybe my neck of the woods has better urologists but I would recommend going with the flow, and staying away from practices that seem to have too many problems. DCIS is another area of conflicted views — treat or not treat, lumpectomy, margin size, mastectomy, double mastectomy. I say have the tests, see the data, and in collaboration with physicians, getting multiple opinions including major centers, take your best shot — but don’t avoid PSA testing, or mammographies because of these controversies — the truth is out there.

  43. It’s your blog simply shut me out. Meanwhile, what are your views on active surveilance. Doesn’t that seem to be a reasonable compromise between no PSA testing and possible undetected agressive prostate cancer and jumping to possible unnnecessary overtreatment or do you think we men should just ignore it and keep our heads in the sand?

  44. It’s your blog simply shut me out. Meanwhile, what are your views on active surveilance. Doesn’t that seem to be a reasonable compromise between no PSA testing and possible undetected agressive prostate cancer and jumping to possible unnnecessary overtreatment or do you think we men should just ignore it and keep our heads in the sand?

  45. I agree with the American Cancer Society:”The American Cancer Society (ACS) does not support routine testing for prostate cancer at this time. ACS does believe that health care professionals should discuss the potential benefits and limitations of prostate cancer early detection testing with men before any testing begins. This discussion should include an offer for testing with the prostate-specific antigen (PSA) blood test and digital rectal exam (DRE) yearly, beginning at age 50, to men who are at average risk of prostate cancer and have at least a 10-year life expectancy. Following this discussion, those men who favor testing should be tested. Men should actively take part in this decision by learning about prostate cancer and the pros and cons of early detection and treatment of prostate cancer.

    This discussion should take place starting at age 45 for men at high risk of developing prostate cancer. This includes African American men and men who have a first-degree relative (father, brother, or son) diagnosed with prostate cancer at an early age (younger than age 65).

    This discussion should take place at age 40 for men at even higher risk (those with several first-degree relatives who had prostate cancer at an early age).

    If, after this discussion, a man asks his health care professional to make the decision for him, he should be tested (unless there is a specific reason not to test).”

  46. I agree with the American Cancer Society:”The American Cancer Society (ACS) does not support routine testing for prostate cancer at this time. ACS does believe that health care professionals should discuss the potential benefits and limitations of prostate cancer early detection testing with men before any testing begins. This discussion should include an offer for testing with the prostate-specific antigen (PSA) blood test and digital rectal exam (DRE) yearly, beginning at age 50, to men who are at average risk of prostate cancer and have at least a 10-year life expectancy. Following this discussion, those men who favor testing should be tested. Men should actively take part in this decision by learning about prostate cancer and the pros and cons of early detection and treatment of prostate cancer.

    This discussion should take place starting at age 45 for men at high risk of developing prostate cancer. This includes African American men and men who have a first-degree relative (father, brother, or son) diagnosed with prostate cancer at an early age (younger than age 65).

    This discussion should take place at age 40 for men at even higher risk (those with several first-degree relatives who had prostate cancer at an early age).

    If, after this discussion, a man asks his health care professional to make the decision for him, he should be tested (unless there is a specific reason not to test).”

  47. It’s just that if men are anything like I was, they will look for any excuse not to be tested. A priori, we don’t want to know. After the fact, we want it out no matter what. Neither approach seems appropriate.

  48. It’s just that if men are anything like I was, they will look for any excuse not to be tested. A priori, we don’t want to know. After the fact, we want it out no matter what. Neither approach seems appropriate.

  49. So what do you think the motivation of the American Cancer Society would be to make recommendations much less aggressive than you put forth? Why would an organization dedicated to preventing and curing cancer not recommend routine PSA?

  50. So what do you think the motivation of the American Cancer Society would be to make recommendations much less aggressive than you put forth? Why would an organization dedicated to preventing and curing cancer not recommend routine PSA?

  51. I can’t speak for them but Dr. Brawley is clearly anti PSA. On the other hand I don’t see major grounds for disagreement with the as you report. But before reaching any decision, I would recommend going over the 2009 reports of American Urological Association and the National Comprehensive Cancer Network. In the end it needs to be a decision of each person (and their significant other) but it makes sense to me that baseline readings should be begin at age 40 for everyone, for example. But would I force a man to have it — no. If I have misread your recommendations, I apologize but the anti PSA forces are coming in all over the place and I may have read into your blog some things others have been saying. Another of my concerns is that future health insurance will follow the USPSTF and I think they are off base.

  52. I can’t speak for them but Dr. Brawley is clearly anti PSA. On the other hand I don’t see major grounds for disagreement with the as you report. But before reaching any decision, I would recommend going over the 2009 reports of American Urological Association and the National Comprehensive Cancer Network. In the end it needs to be a decision of each person (and their significant other) but it makes sense to me that baseline readings should be begin at age 40 for everyone, for example. But would I force a man to have it — no. If I have misread your recommendations, I apologize but the anti PSA forces are coming in all over the place and I may have read into your blog some things others have been saying. Another of my concerns is that future health insurance will follow the USPSTF and I think they are off base.

  53. In the case of men who’ve had no close male relatives live to 40 or 50 (for non-prostate cancer reasons) or who are adopted, would you have the conversation at age 40, 45, 50, or when?
    In theory, you don’t know their risk, really.

  54. In the case of men who’ve had no close male relatives live to 40 or 50 (for non-prostate cancer reasons) or who are adopted, would you have the conversation at age 40, 45, 50, or when?
    In theory, you don’t know their risk, really.

  55. Well, it seems like the anti PSA forces are coming up with all sorts of non health related reasons such as salaries and $$ so presumably there are $$ issues on the other side as well. Are the urologists and equipment manufacturers the only money hungry folks. What’s good for the goose is good for the gander so if money motivates one side of the argument, in probably motivates the other as well. We do need better tests, but like democracy, it’s a terrible system but the best we have. Used with caution it saves lives. The fact that it can and is being misused only means we have to use it better, not throw it out.

  56. Well, it seems like the anti PSA forces are coming up with all sorts of non health related reasons such as salaries and $$ so presumably there are $$ issues on the other side as well. Are the urologists and equipment manufacturers the only money hungry folks. What’s good for the goose is good for the gander so if money motivates one side of the argument, in probably motivates the other as well. We do need better tests, but like democracy, it’s a terrible system but the best we have. Used with caution it saves lives. The fact that it can and is being misused only means we have to use it better, not throw it out.

  57. 40 to 50 I don’t order any unless there is a strong FH. It’s just not common enough in that age group to merit ordering a test that is not that reliable.

  58. 40 to 50 I don’t order any unless there is a strong FH. It’s just not common enough in that age group to merit ordering a test that is not that reliable.

  59. You talk like there is a conspiracy. There really is no reason for anyone to oppose PSA testing aside from scientific reasons. What other motivation would people have to not recommend the test? Having it in for urologists? Militant feminism? The only reason we are not pushing the test avidly is because it has us telling men they have cancer when they don’t. We need a better test.

  60. You talk like there is a conspiracy. There really is no reason for anyone to oppose PSA testing aside from scientific reasons. What other motivation would people have to not recommend the test? Having it in for urologists? Militant feminism? The only reason we are not pushing the test avidly is because it has us telling men they have cancer when they don’t. We need a better test.

  61. Use of the term “anti PSA forces” makes you sound paranoid and takes away your credibility. There are no forces. There are people who believe different than you. Perhaps it is financially motivated, but I can’t figure out how it would be.
    Be careful.

  62. Use of the term “anti PSA forces” makes you sound paranoid and takes away your credibility. There are no forces. There are people who believe different than you. Perhaps it is financially motivated, but I can’t figure out how it would be.
    Be careful.

  63. Some opposed to screening have written books over the years and are now publishing scientific studies to prove that their books were correct. i assume that this increases the sales of books and massages their egos and their pocketbooks. Others will lose patients to specialists. But mainly I would give you all the benefit of the doubt, those for and those against believe you are acting in the best interests of truth and your patients. What I resent is seeing arguments which attempt to discredit urologists because they fly into hospitals in helicopters, have financial gain etc. I agree when it comes to manufacturers of machines and drugs, all bets are off — here the profit motive must be considered the predominant drive and certainly I wouldn’t turn to them for medical advice. As far as “forces” I don’t literally mean an organized group but rather a general mindset. I did note that the good President did not mention prostate cancer in his most recent speech by the way, dropping it but continuing to mention breast and colon cancer, and right in the middle of Prostate Cancer Prevention Month. So the anti PSA forces appear to have infiltrated the White House.

  64. Some opposed to screening have written books over the years and are now publishing scientific studies to prove that their books were correct. i assume that this increases the sales of books and massages their egos and their pocketbooks. Others will lose patients to specialists. But mainly I would give you all the benefit of the doubt, those for and those against believe you are acting in the best interests of truth and your patients. What I resent is seeing arguments which attempt to discredit urologists because they fly into hospitals in helicopters, have financial gain etc. I agree when it comes to manufacturers of machines and drugs, all bets are off — here the profit motive must be considered the predominant drive and certainly I wouldn’t turn to them for medical advice. As far as “forces” I don’t literally mean an organized group but rather a general mindset. I did note that the good President did not mention prostate cancer in his most recent speech by the way, dropping it but continuing to mention breast and colon cancer, and right in the middle of Prostate Cancer Prevention Month. So the anti PSA forces appear to have infiltrated the White House.

  65. Well, that was a marathon! 😉
    As those who read this blog regularly will know (I make no secret of the fact) I don’t work in health care. I do work that sometimes requires the use of balanced risk analysis though. In this technique, you consider the probabilities of preventing an undesirable event, against the probabilities of causing one (not necessarily the same one) by your preventative measures.

    In this case the undesirable event we are trying to prevent is a death from prostate cancer; undesirable events we may cause include unnecessary surgery, death or serious illness from post-operative complications… I’ll leave those who actually are competent in the field to complete the undesirable events table, and compute the probabilities involved.

  66. Well, that was a marathon! 😉
    As those who read this blog regularly will know (I make no secret of the fact) I don’t work in health care. I do work that sometimes requires the use of balanced risk analysis though. In this technique, you consider the probabilities of preventing an undesirable event, against the probabilities of causing one (not necessarily the same one) by your preventative measures.

    In this case the undesirable event we are trying to prevent is a death from prostate cancer; undesirable events we may cause include unnecessary surgery, death or serious illness from post-operative complications… I’ll leave those who actually are competent in the field to complete the undesirable events table, and compute the probabilities involved.

  67. Be sure when you do the computations to do them before and after PSA readings of various kinds, biopsy if appropriate, during active surveillance, etc. Also include the outcome of stuggling with prostate cancer, while still alive. Finally, different undesirable events have different “costs” associated with them, financial as well as health wise and there is the whole quality of life issue. And then there is the individual’s perspective compared to societies perspective — which may be different — I may and probably do value my life much more than public health officials do since they are prepared to trade me for other goals of theirs. Very complicated indeed. To help with medical aspects major cancer centers are developing predictive nomograms. The bottom line is that the more data you can gain but even data comes at some risk so there is a tradeoff there in trying to reach the best estimates.

  68. Be sure when you do the computations to do them before and after PSA readings of various kinds, biopsy if appropriate, during active surveillance, etc. Also include the outcome of stuggling with prostate cancer, while still alive. Finally, different undesirable events have different “costs” associated with them, financial as well as health wise and there is the whole quality of life issue. And then there is the individual’s perspective compared to societies perspective — which may be different — I may and probably do value my life much more than public health officials do since they are prepared to trade me for other goals of theirs. Very complicated indeed. To help with medical aspects major cancer centers are developing predictive nomograms. The bottom line is that the more data you can gain but even data comes at some risk so there is a tradeoff there in trying to reach the best estimates.

  69. Rob, I absolutely empathise (and am the spouse of the upthread-commenting Deirdre). Your point about rampant med-biz salesmanship by Intuitive Surgical, Inc. and doubtless many others is well taken, likewise the statistical weakness of PSA.
    I’ve watched this donnybrook on your blog for a couple of weeks and said nothing because (1) I’m new here, and (2) it seemed likely that miscommunication between you and some commentators was causing the rhetorical brushfire, because you certainly seem to broadly know the material (if you don’t mind a patient’s perhaps impertinent assessment) and are eminently reasonable.

    One place where I think matters went sideways was your passing comment “PSA Testing (the blood test for prostate cancer screening) is by far the largest source of surgical candidates. It is a controversial test, having a high rate of false positives and an unproven record of significant benefit.” This was probably read by many as implying a direct path from serum PSA over 4.0 ng/ml to surgery with no intermediate steps — which is almost certainly not what you meant. In my case, PSA was remeasured a week later to try to disambiguate somewhat from transitory urinary tract infection and other false positives, and that was followed by digital rectal exam (found nothing alarming) and then eventually trans-rectal thin-needle biopsy guided by ultrasound imaging. (Where trend data is available, ratio of free PSA to total PSA is considered also a supporting marker, there being no such data in my case, as I’d just turned 50 and never had the test taken before.) My physician and I had to make the not-completely-obvious judgement call as to whether the estimated risk of aggressive prostate cancer merited the countervailing significant risk of abdominal sepsis from the biopsy itself.

    I’m sure none of that is news to you, but the problem is that your blog analysis seems to (though it probably wasn’t intended to) suggest that Big Med is playing lotto based on nothing better than notoriously error-prone PSA scores, statistically doing 48 aggressive (and expensive) prostatectomies or prostate-nukings to save on average one man’s life — as if there were not a graduated series of diagnostic steps prior to aggressive treatment. Which of course there is. Thus, the sound byte about “Aggressive prostate cancer treatment has to be done 48 times to save one life” (which I’m aware is ERSPC‘s, not yours) is misleading in context — because the recommendation of aggressive treatment isn’t based on elevated PSA, but rather elevated PSA supported by other diagnostic data. (I realise the study is actually somewhat more nuanced than that.) Likewise your “So, an expensive form of surgery that may not be appropriate is done on a group of men identified on a very unreliable test yielding a very small number of lives saved and a lot of men who then have to deal with the physical consequences of the surgery” ignores those same crucial diagnostic next steps, as if they didn’t exist and weren’t routine.

    Your posting also seems to suggest (without so saying, and probably not meaning to say) that doctors are insufficiently distinguishing between dangerous prostate cancer and don’t-worry-you’ll-die-of-something-else-entirely prostate cancer. (E.g., “Prostate cancer screening is controversial, as it fails to differentiate between the minority of men who would die from the disease from the majority who would simply die with it.”) But the whole purpose of screening, which as noted (and as you’re aware) is not just a simple matter of PSA over 4.0 = need for aggressive treatment, is to find the few men likely to have large/aggressive tumours among the many likely to have don’t-worry-about-it tumours without undue risk.

    As stated, your quoted statement, if you’ll (again) excuse my layman’s impertinence, is simply wrong: The screening does distinguish the endangered minority from the shouldn’t-worry majority. That’s exactly what it does. Each diagnostic step is obviously a tradeoff, e.g., I did more than raise an eyebrow at risk from a proposed biopsy serious enough to require the extremely powerful antibacterial ciprofloxacin. The point, though, is that finding the minority (which turned out to include me) does happen, and is the whole game.

    Immediately after the “fails to distinguish” bit you had this: “PSA Testing as greatly increased the number of men diagnosed with early stage cancers.” Yes, and? This seems to suggest (without so saying, and probably not meaning to say) that such men somehow risk becoming grist for the mill of surgery and radiation — but I’m sure you know that is not so. Such men are told “Relax, worry about your blood pressure and sedentary lifestyle instead. We’ll do another $50 blood test every few years to keep an eye on it”: the classic “watchful waiting” outcome to which the vast majority of cases tend.

    But yes, Intuitive Surgical, Inc., is PR-pimping for dollars and doing its level best to pollute public discussion. It’s a point well worth noting.

  70. Rob, I absolutely empathise (and am the spouse of the upthread-commenting Deirdre). Your point about rampant med-biz salesmanship by Intuitive Surgical, Inc. and doubtless many others is well taken, likewise the statistical weakness of PSA.
    I’ve watched this donnybrook on your blog for a couple of weeks and said nothing because (1) I’m new here, and (2) it seemed likely that miscommunication between you and some commentators was causing the rhetorical brushfire, because you certainly seem to broadly know the material (if you don’t mind a patient’s perhaps impertinent assessment) and are eminently reasonable.

    One place where I think matters went sideways was your passing comment “PSA Testing (the blood test for prostate cancer screening) is by far the largest source of surgical candidates. It is a controversial test, having a high rate of false positives and an unproven record of significant benefit.” This was probably read by many as implying a direct path from serum PSA over 4.0 ng/ml to surgery with no intermediate steps — which is almost certainly not what you meant. In my case, PSA was remeasured a week later to try to disambiguate somewhat from transitory urinary tract infection and other false positives, and that was followed by digital rectal exam (found nothing alarming) and then eventually trans-rectal thin-needle biopsy guided by ultrasound imaging. (Where trend data is available, ratio of free PSA to total PSA is considered also a supporting marker, there being no such data in my case, as I’d just turned 50 and never had the test taken before.) My physician and I had to make the not-completely-obvious judgement call as to whether the estimated risk of aggressive prostate cancer merited the countervailing significant risk of abdominal sepsis from the biopsy itself.

    I’m sure none of that is news to you, but the problem is that your blog analysis seems to (though it probably wasn’t intended to) suggest that Big Med is playing lotto based on nothing better than notoriously error-prone PSA scores, statistically doing 48 aggressive (and expensive) prostatectomies or prostate-nukings to save on average one man’s life — as if there were not a graduated series of diagnostic steps prior to aggressive treatment. Which of course there is. Thus, the sound byte about “Aggressive prostate cancer treatment has to be done 48 times to save one life” (which I’m aware is ERSPC‘s, not yours) is misleading in context — because the recommendation of aggressive treatment isn’t based on elevated PSA, but rather elevated PSA supported by other diagnostic data. (I realise the study is actually somewhat more nuanced than that.) Likewise your “So, an expensive form of surgery that may not be appropriate is done on a group of men identified on a very unreliable test yielding a very small number of lives saved and a lot of men who then have to deal with the physical consequences of the surgery” ignores those same crucial diagnostic next steps, as if they didn’t exist and weren’t routine.

    Your posting also seems to suggest (without so saying, and probably not meaning to say) that doctors are insufficiently distinguishing between dangerous prostate cancer and don’t-worry-you’ll-die-of-something-else-entirely prostate cancer. (E.g., “Prostate cancer screening is controversial, as it fails to differentiate between the minority of men who would die from the disease from the majority who would simply die with it.”) But the whole purpose of screening, which as noted (and as you’re aware) is not just a simple matter of PSA over 4.0 = need for aggressive treatment, is to find the few men likely to have large/aggressive tumours among the many likely to have don’t-worry-about-it tumours without undue risk.

    As stated, your quoted statement, if you’ll (again) excuse my layman’s impertinence, is simply wrong: The screening does distinguish the endangered minority from the shouldn’t-worry majority. That’s exactly what it does. Each diagnostic step is obviously a tradeoff, e.g., I did more than raise an eyebrow at risk from a proposed biopsy serious enough to require the extremely powerful antibacterial ciprofloxacin. The point, though, is that finding the minority (which turned out to include me) does happen, and is the whole game.

    Immediately after the “fails to distinguish” bit you had this: “PSA Testing as greatly increased the number of men diagnosed with early stage cancers.” Yes, and? This seems to suggest (without so saying, and probably not meaning to say) that such men somehow risk becoming grist for the mill of surgery and radiation — but I’m sure you know that is not so. Such men are told “Relax, worry about your blood pressure and sedentary lifestyle instead. We’ll do another $50 blood test every few years to keep an eye on it”: the classic “watchful waiting” outcome to which the vast majority of cases tend.

    But yes, Intuitive Surgical, Inc., is PR-pimping for dollars and doing its level best to pollute public discussion. It’s a point well worth noting.

  71. You should know from the name of this blog that comments over 4 sentences in length will give me trouble.
    I never meant to dis PSA testing here; my point was that the device manufacturers care little about the science. They are driving reimbursement far too much.

  72. You should know from the name of this blog that comments over 4 sentences in length will give me trouble.
    I never meant to dis PSA testing here; my point was that the device manufacturers care little about the science. They are driving reimbursement far too much.

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