Rethinking shared decisions in prostate cancer screening

Last October, the U.S. Preventive Services Task Force provisionally recommended against screening for prostate cancer using the prostate-specific antigen (PSA) test, eliciting a variety of reactions from medical and patient advocacy groups. The New England Journal of Medicine published one of the most thoughtful responses by Mary McNaughton-Collins and Michael Barry, two physicians who have done a great deal of research on the psychological and physical harms related to false-positive tests, an all-too-common occurrence in men who receive periodic PSA testing. They respectfully disagreed with the USPSTF's "D" (don't do) rating for this preventive service, arguing that the rating should have instead been a "C" (don't do routinely):

A grade C recommendation would allow the patient to be involved in the decision to skip or choose a PSA screening test, after a discussion with a primary care provider about the magnitude of the known harms and the potential for some benefit. The patient could then provide his perspective on how he views the trade-off. Weighing the pros and cons to make a decision about PSA screening is an individual process, and different well-informed men will make different decisions. A grade D recommendation removes the patient from the equation and puts the physician in the central position of discouraging use of the test. Uncertainty in medicine is more common than we usually let on, and the way to address uncertainty is to allow patients the central position in decision making. ... We do not believe that anyone but the patient should decide whether the small and uncertain benefits of PSA screening are worth it.

In 2010, the American Cancer Society took a similar stance, recommending that men age 50 years or older make "informed choices" about whether or not to receive the PSA test after being provided with detailed information about the risks and benefits and tools to help them make the decision. On the surface, both of these recommendations seem more reasonable that the USPSTF's. Rather than making a unilateral decision for every patient based on imperfect population-level evidence, why not let each patient make the choice for himself?

The answer is that primary care physicians have already been trying this approach for many years, and it does not work. Numerous studies have shown that no matter how much information men are given in any format, the vast majority still choose to receive the test, and most of them end up worse off because of that decision. In fact, as a new study concludes in the Archives of Internal Medicine, once prostate cancer is diagnosed via PSA testing, the men most likely to receive aggressive ("curative") treatments are those who are least likely to need it - men who would have been better off not getting the test in the first place.

A case in point: in the same issue of the journal, an academic oncologist who exclusively cares for prostate cancer patients tells the story of his own concerning PSA test, prostate biopsy, and subsequent decision to undergo radical prostatectomy at age 56. Five years later, he is cancer-free, but has permanent right-sided weakness as the result of the surgery, which was in retrospect unnecessary given the limited spread and good prognosis of his tumor. He laments: "Even the most informed patient (me in this case) has difficulty making a truly informed decision." And if a physician who spent decades caring for patients with prostate cancer has trouble making the right call, what hope is there for the rest of us?

Physician-researcher H. Gilbert Welch (author of Overdiagnosed, previously reviewed on this blog) recently challenged the consensus that informed decision-making is the best approach to PSA testing:

I worry that excessive fealty to informed decision-making in cancer screening may distract us from more important issues—like what is bothering patients right now. It may also lead physicians to abdicate our role as advisor—physicians simply transfer responsibility to their patients. And the problem appears to be asymmetric: we seem less inclined to recommend against than to recommend for. ... Why are we so reluctant to make value judgments about things not to do to patients? Is it because we are so fearful of potential litigation? Is it that we have become so financially conflicted? Or is it that we fear being accused of caring about cost? Maybe clinicians need the Task Force to make the call for us. And, for PSA testing, they did. If I was pressed to get off the fence, it's the call I would have made.

I couldn't agree more. Shared decision-making in PSA screening is an attractive concept that in practice leads to more harm than good. The Task Force was right to recommend that it stop, and that we instead advise patients not to get the test.

Cutting Prevention Fund to pay for 10 month "doc fix" is medical #Linsanity

Like millions of basketball fans around the world, I've been transfixed by the story of Jeremy Lin, the undrafted Taiwanese American point guard from Harvard who has taken the NBA by storm this month as the new superstar of the New York Knicks. It doesn't hurt that we share a last name, ethnic background (both of my parents immigrated from Taiwan), and Crimson alma mater. But otherwise, the title of this blog post and the below YouTube video of Lin's latest athletic exploit (a steal and dunk en route to 28 points and a win over the defending champion Dallas Mavericks) is a shameless ploy to get you to read about a current health issue that's just as #Linsane in its own way.



Last week, Congress agreed to extend Social Security payroll tax cuts and delay by ten months a 30 percent cut to physicians' Medicare payments (also known as the "doc fix") in part by raiding the Prevention and Public Health Fund, created by the 2010 Affordable Care Act to meet critical clinical and community needs such as childhood immunizations, tobacco cessation, and obesity and diabetes prevention. The Fund was initially allocated $21 billion over ten years; this number was cut to $16 billion in President Obama's FY 2012-13 budget proposal and slashed to $11 billion by the latest Congressional action. $11 billion still sounds like a lot, but it's a paltry fraction of the estimated $2,600,000 billion that the U.S. spends on health care each year, and now nearly all of the Fund will merely offset draconian cuts to state public health programs due to the recession, rather than paying for new or expanded prevention initiatives. (If you have any doubts that we need to do much more as a nation to fight obesity, see these graphics on state obesity trends from the Centers for Disease Control and Prevention.) And of course there's no guarantee that the remaining funds will be protected when Congress looks to extend the doc fix at year's end.

Journalist Merrill Goozner tartly observed that cutting 10 years of prevention funds to pay doctors for 10 months is like "selling your home's storm doors to pay for this winter's heating bills." Alas, this penny-wise, pound-foolish decision was predictable. As Yale Prevention Research Center Director David Katz, MD argues, public health programs are chronically vulnerable to budget cuts because "prevention at its best is as dull as watching paint dry":

Let's face it -- a heart attack that doesn't happen lacks drama. The bout of influenza someone doesn't get lacks flare. When prevention and public health work well, you see just about none of what you get. You get a lot, and see ... nothing. When we talk about what prevention could do -- eliminate 80 percent of all heart disease, 90 percent of all diabetes, up to 60 percent of cancer and so on -- it is all in terms of some anonymous public. We are hard-wired to shrug our shoulders about that, and carry on. In contrast, Whitney Houston had a name and face and voice we all knew -- and for the loss of that, we readily feel passion and shed tears.

But consider for a moment the people you love who have been touched by heart disease, cancer, stroke or diabetes. Recall the visit to the hospital, the dreaded phone call. Now consider that prevention funds, used wisely, could make that experience go away fully eight times in 10. Prevention funds, used wisely, could help us give our children a world in which those horrible phone calls and anxious trips to the ER and ICU are mostly gone.

It's all too easy for the prevention fund to be about a public with no face and no name. But when we part the veil of statistical anonymity, the faces looking back at us are the faces of people we love. Those in Congress swinging the [budget] axe simply didn't pause to part the veil.

Life and career transitions

As I wrote about in a previous post, my wife and I are expecting our third child to be born any day now. Along with this joyful transition in my family life, I'm looking forward to an upcoming career transition as well. In mid-April, I will re-join the full-time faculty in the Georgetown University Department of Family Medicine, where my responsibilities will include directing the Primary Care Health Policy Fellowship, seeing patients in a model family medicine practice, teaching medical students and residents, and continuing my editing work with the American Family Physician journal. I'm excited about working more closely with family physician colleagues (many of whom I've known for several years or more) in this dynamic and productive department. I will continue blogging on Common Sense Family Doctor, of course, but it's possible that you may be reading more posts about medical education than in years past.

How many physician referrals is too many?

Most clinical review articles about health conditions that may require co-management of specialist physicians contain a short section or Table titled "Indications for Referral." For example, a recent article on prevention and care of outpatient burns includes a list of criteria from the American Burn Association for considering the transfer of a patient to a burn center. This and other lists generally represent expert consensus on appropriate reasons to refer a patient in a typical primary care setting; obviously, availability and accessibility of specialists has a large influence on a family physician's practice with regard to management of "referable" conditions. Clinicians' training and expertise also affect their comfort levels in caring for patients with complex problems and, as previous studies have shown, these factors lead to variations in referral rates.

Despite variations in referral rates among individual physicians, there is a clear trend in the U.S. toward more referrals. An analysis of ambulatory care survey data from 1999 to 2009 recently published in the Archives of Internal Medicine found that the probability that an office visit resulted in a referral nearly doubled during this time period, from 4.8% to 9.3%. It isn't clear why this is happening, or what percentage of those referrals are appropriate. Medicine may be becoming more complex, or patients may be presenting with more problems that cannot be effectively dealt with in an office visit that is the same length as it was 10 years ago.

What is clear is that at a time when a coalition of national primary and specialty care organizations is leading a campaign to reduce overuse of health care resources, the impact of this dramatic increase in referrals cannot be ignored. But in the absence of evidence-based standards for when to refer, how many referrals is too many? Is this even an answerable question? And if it is, what can be done about it?

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The above post was first published on the AFP Community Blog.