OK, OK … Both my sister and daughter have wanted to know what I think about the most frequently mailed post in the current New York Times. (please read it before reading on if you haven’t seen it) The author laments his discovery of PSA, an enzyme made by the prostate that leaks into the blood stream, but leaks even more if you have cancer. . .
PSA testing took off like a rocket. As Otis Brawley [head of the American Cancer Society] put it last weekend at the ASCO GU [American Society of Clinical Oncologists -- genitouritary] Symposium, it was a case of “faith based practice versus evidence based practice”. The evidence took a long time to develop, but it is now here. I have blogged elsewhere in this forum about the two large screening studies published last year in the New England Journal of Medicine that raise serious concerns about what we have done. But this was not the first time experts in the field have raised questions. For example, a wonderful editorial in the Lancet in 2002 was entitled “Eradication of a disease: how we cured symptomless prostate cancer”.
My own view is that we are finally waking up and that PSA testing is just one of many things that society (particularly U.S. society) needs to be looking at in controlling health care costs. The billions of dollars spent on earlier testing, earlier and more expensive (but not necessarily better) treatments for prostate cancer, and treatments with limited effectiveness for the unfortunate patients late in their disease course should be looked at with some harsh reality testing. We can’t afford to ruin this wonderful country of ours by spending everything we have on health care while we ignore the educational needs of our kids, innovations needed in energy, and fixing potholes in our roads.
I personally like the idea of panels that look at cost-effectiveness and decide where to draw the line on what our insurance (Medicare, Medicaid, private…non profit I would propose, and so on should pay for). Yes folks, this is RATIONING. We already do it in a haphazard manner by not insuring the sick. PSA testing may be something we shouldn’t pay for. Those with proper information who wish to be tested should be allowed to do so, but…
My bottom line is that I think PSA testing has saved some lives. But it has been at the huge financial, emotional, and physical (incontinence, impotence, etc.) expense to dozens of men for every life saved. Churchill said, “Never in the field of human conflict was so much owed by so many to so few.” In this case it is the few who owe a debt to the many I would guess.
He also said, “If we open a quarrel between past and present, we shall find that we have lost the future.” It is time to become realistic about the limits of medicine and make some hard choices about our future.”