Could the decline in #prostatecancer diagnoses usher in an increase in death rates? #cancer screening

CaptureThere are a lot of problems with cancer screening. Explaining and understanding the calculus behind the tests is not easy.  Suffice to say that early detection is generally not the life saver we thought it would be.

Now comes a steep decline in prostate cancer diagnoses. Harvard’s Meir Stampfer asks where that’s good news or bad news. Writing mostly behind the pay wall in JAMA Oncology he notes:

Prostate cancer rates in the United States are down—sharply… a decline of 53% since 1992, when prostate-specific antigen (PSA) screening became widespread. This decrease is likely attributable to 2 factors. First, after more than 3 decades of widespread PSA screening to detect prostate cancer, there are few men with high PSA levels that haven’t already been diagnosed. Second, and perhaps more important, PSA screening is now becoming less common.In 2008, the US Preventive Services Task Force (USPSTF) advised against PSA screening for men older than 75 years. Screening then declined in all age groups.

He cites a study release this past fall, that found screening reduces mortality. It follows another study that found no reduction.

The questions is, he ask –will drop in mortality stop or reverse as screening declines?

Stampfer note that here is a lot of undiagnosed prostate cancer out there. Most cases, he writes, will never cause harm. Some will, but the PSA test is not specific enough to sort out the lethal cases. Watch at wait is one response. But, if the cases are never diagnosed, no one will be watching.

So, good or bad news? He’ll address that question on Wednesday, January 10, at the Harvard School of Public Health.  Details here. 

Worth noting that, according to Health News Review, a recent study “confirms what we already know about the PSA test — that it involves trade-offs including financial costs and long-term harms from screening in exchange for what appears to be very few numbers of lives saved. It is in knowing and understanding these trade-offs that men can be sure that they are going into a PSA test with their eyes wide open.”

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Overdiagnosis or overtreatment? Move to lung cancer screening fuels debate

A report from HLM on Siemens-sponsored, Atlantic-hosted event on “The Diagnostic Debate.”

Gregory Sorensen, the CEO of Siemens Healthcare North America opened the session by challenging the notion that screening drives overdiagnosis.

“We’re not over diagnosing,” he said. “We’re over treating.”

Sorensen used as an example, mammography. When doctors find a “low-grade” tumor like DCIS (ductal carcinoma in situ), they may resort to a lumpectomy or chemotherapy despite questions about the efficacy of those treatments, he explained.

“This in turn leads us to question the value the mammography, because it leads to overtreatment. It is not the mammogram that’s the problem,” Sorensen asserted. “It’s the [healthcare] system’s lack of discipline.”

Atlantic’s event site. 

 

Health policy digest takes on reform loopholes and clueless reporters

The latest edition of the roaming digest of health policy blogs;

Health Wonks – the SuperHero Edition!!!

The deficit battle is on and politicians are in full voice – both in Washington and out on the hustings, where GOP candidates are loudly denouncing health reform as unAmerican and a job killer.  Hipsters and greying hippies are occupying Wall Street and Main Street, while Tea Partiers are claiming they hold the title of most outraged.  The one percent is wondering what the 99 percenters are so upset about, while the 99 percenters are after their well-coiffed scalps.

Into the bloody fray, with nary a fear for life or health, reputation or career, plummet our worthies, those denizens of the blog-o-sphere that specialize in separating the non- from the -sense, the BS from the fertilizer, the ill-formed opinion from the logically-based interpretation!

Join us as we follow their heroic deeds, gasp as you read their trenchant and timely missives, awed by their grasp of the incredibly-esoteric and yet critically important.

Boston Globe editorial: Prostate screening limits “too sweeping”

A staff editorial in today’s Globe echoes comment made by prominent docs in town: The US Preventative Services Task Force went too far in calling for limits on prostate screening.

A better course would be for physicians to talk with their patients about both the uncertainties inherent in the PSA test and the relative innocuousness of most prostate cancers. Some patients may find the panel’s recommendation reason enough to forgo the test. Others patients might prefer to have it done, but to monitor their PSA levels rather than seek immediate treatment when the results are borderline.

Insurance companies often use the panel’s recommendations as their criterion for whether to cover a test. But until there’s a better test to detect prostate cancer or a broader consensus about skipping this one, insurers should continue to cover it.

Note that The New York Times editorial staff supports the limits and notes that the USPSTF guidelines allow for doctor patient conversations:

Critics, including urologists, who diagnose and treat prostate cancer, charge that the task force’s recommendations are misguided and will hurt patients. They have already been held up for two years lest they ignite charges of government rationing. That’s absurd. The recommendations are intended as guidance to help men and their doctors decide whether to use the test and how to react if it is positive. This is information patients need to know.       

 

Globe on reform and the cost of screening

See KHN and the usual suspects for the news on the possible demise of the public insurance plan option in the reform package.  

The Globe offers a story this morning about the cost-saving potential of preventive health and screening. 

While cholesterol tests, cancer screenings, and other preventive measures can save lives, there is strong disagreement about whether they really reduce health care spending, because the tests themselves are costly and often lead to more doctor’s visits and procedures. And now, that longstanding medical debate has become a big political sticking point

Here’s a link to the NEJM article mentioned in the Globe and another to Tufts program: The Center for the Evaluation of Value and Risk in Health.

My comment — I would not lump screening and prevention together.  Encouraging exercise is not the same as sending someone out for a questionable heart scan. Here’s a story from the NY Times on questions about the conventional wisdom of cancer screening.