Should Obama Get a PSA Test? On Prostate Cancer Screening and Comparative Effectiveness. That's the headline of Dr. Bernadine Healy's blog entry on the US News & World Report website.
I felt obliged to respond online with a comment in reaction. I wrote:
Dr. Healy writes: "Prostate cancer mortality rates have plummeted in the United States over the past 20 years, coinciding with the widespread use of PSAs. (No such drop has occurred in Europe, where PSA screening, by policy, is uncommon.) This suggests—though it certainly doesn't prove—that PSA screening saves lives."
However, if more silent cancers that never would have killed American men are now being found because of more American PSA testing, then by default, the mortality rate would plummet. You're now calling more things "cancer" – many of which wouldn't have killed a man anyway. Dr. Barry Kramer of the National Institutes of Health calls it a pseudo-epidemic. So Dr. Healy’s example certainly DOESN'T prove that PSA screening saves lives.
And the entire premise of the article about whether the President should get a PSA test - while provocative and probably meant to catch eyeballs - misses the conclusion most experts reached after the recent studies. When evidence raises so many questions about PSA screening, it becomes essential that a man discuss the potential benefits AND harms with his own caregiver. It's not an item up for debate by a magazine or by a urologist who won't even see the President.
With all of the questions swirling around the issue of prostate cancer screening, there has never been a greater need for shared decision-making between physicians and their patients.
To set the scene for an informed physician-patient encounter, the Foundation for Informed Medical Decision Making - through its partner Health Dialog - now offers free online access to its excellent Shared Decision Making program, "Is a PSA Test Right For You?"
Disclosures: The Foundation funds my work on the HealthNewsReview.org project. And I worked for that Foundation throughout the 90s, and produced the original version of this prostate cancer decision aid 15 years ago.
The Foundation has been urged to make this program available to the general public for years. I'd be interested in hearing any reactions after you view it.Stumble It!
For years I have tried to reach journalists who unquestioningly promote prostate cancer screening in all men 50 or older - some have promoted it in all men even 40 or over. But the National Cancer Institute trial - the results of which were published today - shows that questions must be asked.
Read the study.
AP's Lauran Neergaard wrote a good story about the shared decision-making focus of last week's Foundation for Informed Medical Decision Making (FIMDM) Policy & Research Forum in Washington, DC.
A new University of Michigan study of how 3,000 patients made common medical choices suggests patients frequently have misinformation. Fewer than one in five could name the most common side effect of cholesterol-lowering statin drugs they were considering, for example. Moreover, patients said their doctors discussed treatment advantages more than the disadvantages.
As promised, I'll blog more about this Forum when I get the chance. Fascinating data worthy of more attention.
For now, you should go to the FIMDM website, and click on the middle section labeled, "Transforming the Patient Experience: Four stories of informed decision-making." The video available there is a terrific demonstration of shared decision-making through the words of four actual patient examples. Watch the video. It's time well spent.
An Australian pain specialist writes an intriguing letter to the BMJ this week, entitled, "What if back surgery was a drug?" He wrote:
"I find it fascinating that surgical treatments and medical treatments are evaluated very differently in the literature and by ethics committees. Let’s say you told a human research ethics committee (HREC) that you expected only a short to medium term reduction in radicular pain (editor's note: that means pain that radiates from the back to the legs - or sciatica) with no real improvement in disability or axial back pain for a drug treatment. You go on to say that treatment had a 70% chance of entrenching the axial back pain as permanent, a 5% chance of worsening the pain, 1% risk of permanent neurological damage, with lesser chances of major vessel damage or paraplegia, I wonder how many HRECs would approve it ? If you then presented a literature search that relied mainly on a 30 year old study with major design flaws and a couple of meta-analyses of poor data you could reasonably expect to be sent packing. By way of comparison, in Australia last year lumiracoxib was banned by the Therapeutic Goods Administration for causing fulminant hepatitis at a rate of one in 15,000, with two deaths out of an estimated 60,000 patients who received it.
Without a standard battery of outcome measures which can be used in both surgical and non-surgical trials, and without sham surgical studies, which must measure pain related disability and psychological outcomes (since there is clear evidence that these influence overall disability in a major way) it is difficult to interpret the vast but mostly useless back pain literature."
That is why evidence-based and shared decision-making - which presents a balanced presentation of tradeoffs, of harms & benefits, and of uncertainties - is so important.Stumble It!