Thursday, March 23, 2017

#No2AHCA and positive trends in prostate cancer screening

Without a doubt, today's biggest health policy story is the anticipated House of Representatives' vote on the American Health Care Act, the first step toward fulfilling President Trump's campaign promise to "repeal and replace" the Affordable Care Act. I outlined my position on the AHCA in detail in my latest Medscape commentary; for those of you who are not health professionals, suffice to say that I don't think it will do anything to improve the lives of patients, caregivers, or primary care physicians. Even the AHCA's strongest selling point - billions of dollars saved for the federal government over the Congressional Budget Office's 10-year time horizon - is achieved by shrinking premium tax credits relative to costs to make insurance policies unaffordable for more people (meaning that they will not be able to actually use the tax credits) and forcing states to carry more of the financial burden of Medicaid or (more likely) drop people from their programs. The result is that the AHCA, if passed, could actually result in one million fewer people having health insurance than if the ACA was simply repealed.

The bottom line is that the AHCA doesn't reduce the cost of health care; it just shifts more of those costs on to the backs of people who are least able to afford them.

If we want to actually reduce costs, we can start by not providing health care services that are unnecessary, ineffective, or potentially harmful, which is the premise of the Choosing Wisely campaign, the Right Care Alliance, and the Too Much Medicine initiative. There is some good news on this front: a research letter published this week in the Annals of Internal Medicine reported that among men aged 40 to 64 years who received health insurance from Aetna between 2009 and 2015, substantially fewer are receiving PSA screening, prostate biopsies, and prostate cancer treatments. This finding suggests that U.S. physicians are screening more selectively, raising the threshold for biopsy, and for men with a prostate cancer diagnosis, choosing watchful waiting or active surveillance more often than aggressive therapy with its associated side effects. Thank you, U.S. Preventive Services Task Force.

In my practice, after I counsel older men about projected benefits and harms of PSA screening, some will still choose to have the test, but more will decline. Many men in the latter group ask me if there are any better tests in development, and my answer is yes, but they aren't yet ready for routine use. HemeOnc Today recently invited me to respond the question: "Is genetic testing sophisticated enough to make PSA screening viable for mainstream use?" Below is an excerpt from my "No" response:

The search is on to identify more specific biomarkers that can either replace PSA as a screening test, or augment PSA by predicting which men with elevated levels are at the greatest risk for harboring clinically important — and potentially curable — cancers. However, utilizing genetic tests for this purpose outside of clinical trials is premature. The only genetic test for prostate cancer approved by the FDA is the PCA3 urine assay. In 2014, the Evaluation of Genomic Applications in Practice and Prevention Working Group concluded that PCA3 has insufficient supporting evidence to inform decisions to conduct initial or repeat biopsies for prostate cancer in at-risk men. ...

A 2016 systematic review commissioned by Agency for Healthcare Research and Quality found insufficient evidence to assess analytic validity of 18 commercially — or close to — available multigene panels for prostate cancer risk assessment, evidence of modest clinical validity beyond patient age and family history, and no studies of clinical utility (eg, effects on process of care, health outcomes, harms and economic outcomes).

It is understandable that physicians and patients who are concerned about prostate cancer are impatient for new tests that promise to maximize the benefits and minimize the harms of PSA testing. But we should have learned our lesson from the PSA experience. Now is not the time to perform more uncontrolled experiments on older men by incorporating unproven genetic tests into clinical practice.

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