Friday, November 4, 2011

PSA and the Presidential Physical

Earlier this week, the White House released the results of President Obama's periodic physical examination. Pronounced "fit for duty" by his personal physician, the President, who turned 50 earlier this year, had an unremarkable examination and normal blood sugar and cholesterol levels. Also, it seems that he's finally managed to stop smoking - good for him. Interestingly, President Obama went against the advice of the U.S. Preventive Services Task Force and chose to receive a screening prostate-specific antigen test (which was normal), but, perhaps in recognition of the Task Force's recent finding that the PSA's harms outweigh its benefits, his physician felt it necessary to note in parentheses that this was an "informed patient request." There's no indication whether or not the President used any shared decision aids (such as this one from the Family Medicine department at Virginia Commonwealth University) to decide to undergo screening, but given the lengths his Administration went to prevent the new prostate recommendations from being released in the first place, this surely represents a small victory of science over politics.

Here's what I wrote on March 1, 2010 about the President's previous physical examination.


Based on standards set by the U.S. Preventive Services Task Force (USPSTF), the widely respected independent committee of primary care health professionals that for more than 25 years has rigorously reviewed the evidence for benefits of clinical preventive services, President Obama's recent physical examination contained at least 3 screening tests that were either unnecessary or of uncertain health benefit. These tests included:

A prostate-specific antigen (PSA) test for prostate cancer. In 2008, the USPSTF found insufficient evidence that this test reduced mortality from prostate cancer, and 2 subsequent long-term studies of PSA screening published in March 2009 reported no mortality benefit and a very small survival benefit limited to men ages 55 to 69 years, respectively. (President Obama is 48 years old.)

A coronary calcium scan for coronary heart disease. In 2009, the USPSTF found insufficient evidence that patients who test positive and receive treatment for coronary artery blockages have fewer heart attacks compared to similar patients who don't have the test.

CT colonography ("virtual colonoscopy") for colorectal cancer. Most guidelines, including the USPSTF's, recommend that colorectal cancer screening start at age 50 in persons without a family history. However, in 2008 the USPSTF found insufficient evidence that CT colonography was as effective as older, established tests such as fecal occult blood testing and optical colonoscopy, exposed patients to higher doses of radiation, and commonly leads to unforeseen consequences of incidental scan findings in other parts of the abdomen. Based largely on these concerns, in 2009 the Centers for Medicare and Medicaid Services declined to extend Medicare coverage to CT colonography.

A colleague of mine argued that the Leader of the Free World might be subject to different standards than you and me, given the psychological impact it would have on the nation and the world were President Obama to be suddenly felled by a heart attack or belatedly diagnosed with metastatic prostate or colorectal cancer. But this argument cuts both ways. What if his PSA test (reportedly a normal 0.70) had been slightly high, leading to a prostate biopsy that showed a low-grade cancer? Or if the coronary calcium scan had suggested a non-critical blockage in a coronary artery? Or if CT colonography had picked up a suspicious mass on a kidney that couldn't be distinguished from cancer? All of these results would have potentially been false positives, but would have required additional invasive diagnostic tests and treatments with important adverse effects.

The experience of the late President Reagan, who underwent surgery during his Presidency to remove an apparently malignant colon tumor, reminds us that even the perception of poor Presidential health can dramatically affect the psyche of the nation. So regardless of your political persuasion, we should probably be happy that President Obama's physicians gave him a "clean bill of health" this time around. At any rate, I hope that they counseled him to stop smoking and offered medications to help him quit - a preventive service that the USPSTF reaffirmed in 2009 with an unequivocal "A" recommendation.

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