Thursday, September 4, 2014

PSA screening for prostate cancer: a bad idea then and now

Few scientists have been fortunate enough to make a single discovery that ultimately revolutionized the practice of medicine. So one might expect Dr. Richard Ablin, who identified prostate-specific antigen (PSA) more than forty years ago, to take satisfaction in the way his accomplishment has transformed the field of urology and the way clinicians detect and treat prostate cancer in the twenty-first century. A study published last week in JAMA Internal Medicine found that even though three major guidelines – from the U.S. Preventive Services Task Force (USPSTF), the American College of Physicians, and the American Urological Association  raise serious concerns about the PSA test's effectiveness and adverse effects, nearly one-half of all men between the ages of 65 and 74 reported being screened with the PSA test within the previous 12 months.

But after reading Dr. Ablin's 2010 New York Times editorial, "The Great Prostate Mistake," and his revelatory followup book, The Great Prostate Hoax, I think he probably feels that the world would have been better off if PSA had remained undiscovered  or, at least, if his discovery had not been so shamelessly exploited by the medical-industrial complex to cause erectile dysfunction and urinary incontinence in a generation of terrified men who had surgery for screen-detected prostate cancers that otherwise would not have bothered them at all.

As longtime readers know, I played a minor role in this saga. Dr. Ablin mentions me on page 174 of his book, during his recap of the excruciating delay between the USPSTF's initial (and unanimous) vote to recommend against PSA screening and the final publication of that report:

According to Michael L. LeFevre, MD, the vice chairman of the task force that issued the [2012 USPSTF] report, in 2009 he and his fellow panel members had voted to recommended against PSA testing, but knowing they would have to defend themselves against the inevitable firestorm of criticism – from the AUA and advocacy groups – they slowed the process down, issuing their recommendation three years later in 2012. … 

Kenneth Lin, a central researcher on the PSA review panel, resigned in protest. How many men might have been spared an unnecessary life-changing radical prostatectomy during that delay? ... LeFevre’s admission speaks to the culture of fear promulgated by the prostate cancer industry. And in this case the industry won. Between 2009 and 2012, it obtained a three-year window of opportunity during which more than 3 million more men had painful needle biopsies and about 300,000 of those men needlessly had their prostate glands cut out of their bodies.

It wasn't just the "prostate cancer industry" that was supplying fear and pressure. After being thrown under the bus by the Obama administration when the furor over downgrading its recommendation on breast cancer screening for women in their 40s threatened to derail the Affordable Care Act, USPSTF members weren't convinced that they could count on the Department of Health and Human Services to protect them from prostate cancer fallout less than a year later. They were right to worry. In October 2010, my boss at the Agency for Healthcare Research and Quality received explicit instructions from the White House to call off the Task Force's November meeting (where prostate cancer screening would be reconsidered). With no good options, Dr. Ned Calonge, the outgoing Chair, decided to cancel the meeting himself, allowing the USPSTF to save face and not be pigeonholed as a partisan panel that only produced scientific statements supportive of the administration's goals (which, to my jaded eye, boiled down to extolling the benefits of "free" screenings and downplaying or shelving inconvenient evidence of harm).

Today, Dr. Ablin is hardly alone in calling for an end to PSA screening for prostate cancer. Dr. Vinay Prasad, who has written widely about medical reversals, recently chimed in with "It Is Time To Stop Screening for Prostate Cancer," where he observed that "the history of the PSA test will one day serve as a reminder that, although all of us in health care want to do everything possible to reduce the mortality of cancer, the early adoption of screening techniques on the basis of insufficient evidence can lead to more harm than good." I could not agree more. PSA screening is a tragedy born from physicians' good intentions. It was a bad idea when it began in the evidence-free world of the early 1990s, and it continues to do far more harm than good to older men today.