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This just in from the New England Journal of Medicine, two large studies adding futher evidence that much of our medical screening and interventions are doing more harm than good, this time with the Prostate Specific Antigen (PSA) test, which is used to screen for prostate cancer in men. For the past twenty years, yearly PSA screening with rectal exam has been recommended, based, of course, on little or no evidence that it is useful, just the assumption that it “couldn’t hurt” or “if I had a cancer I’d want to get it out.” So most American men get the tests. The Europeans do it much less commonly, as one of them pointed out “we think differently about these kinds of things than the Americans.”
Oui oui.
So on to the studies. The first study from the Americans, the Prostate, Lung, Colon and Ovarian (PLCO) Cancer Screening Study, involved 76,693 men who were randomly assigned to receive PSA screening and rectal exam every year for six years or have usual care. Although more prostate cancer was diagnosed in the screened group, they didn’t have more prostate cancer related deaths after seven years.
More prostate cancer diagnosed, but no difference in prostate cancer death rates
After ten years there were no differences in deaths between those who got screened (50) and those who did not (44), a 13% higher death rate in the screened group that wasn’t statistically significant.
In the European Randomized Study of Screening for Prostate Cancer 182,000 men age 5-74 were randomly assigned to PSA screening every four years or not receive screening and followed for an average of nine years. There were more prostate cancer diagnoses and 20% fewer prostate cancer deaths in the screened group, a difference that was statistically significant. The absolute difference was 0.71 per 1000 men meaning 1,410 men would need to be screened and 48 men treated to prevent one prostate cancer death. There was no difference in overall death rates.
No difference in mortality with screening for prostate cancer
Dr. B’s comment: Not all cancers are created equal. Most men identified as having abnormal tests will probably never develop a prostate cancer that will kill them (a similar situation holds for mammography). Prostate cancer screening is resulting in men getting a lot of unnecessary treatments that can be associated with impotence and incontinence. The lack of difference in death rates probably means that for every man “saved” from prostate cancer there is one many who has died from radiation treatments when their prostate cancer never would have killed him in the first place.
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RT @DrShock: Prostate Cancer Screening Useless http://tinyurl.com/chy7un #?
Prostate Cancer Screening Useless http://tinyurl.com/chy7un
thank you…my google reader was filled with literally a dozen or more articles on this study…I’m forwarding your piece to my husband as you cut through the crap nice and cleanly!
thanks.
Doug==I keep hearing there are more useful dx tests–”free PSA,” the whole velocity issue, etc. Do none of these things change the risk/benefit issue? Do we have any data? To the degree some urologists used finer grained criteria, I assume they’d be washed out in these large studies. No?
Why didn’t they just ask me what I thought? Would’ve saved a lot of time.
What about the psychological value provided to those of us who leave the doctor’s office each year having been told: “You’re PSA is fine”? I take the point that if I learn that my PSA level is raised I’ll be faced with a quandary, but so far I’m happy to be told this is one thing I don’t need to worry about (notwithstanding the possibility of false negative results).
Dear husband,
you misspelled my name!
oops! Good job it’s a pseudonym
Ha ha! Very funny all. Glad we finally flushed out Mr. Kali. As for more ‘sensitive’ tests I think the problem is that the prostate is a very plastic organ and so anything that measures ‘neoplasticity’ is going to be fraught with the overkill or false positive problem. Same goes for breast. As for the psychological factor of being told you are normal it is not worth the risk of getting the false positives and having to go through all the worry, biopsies, etc.
I knew it.
Plastics.
Nevertheless, I still eat my tomato sauce and broccoli sprouts in order to go with the flow. Never made sense to me why those guys in the Flomax ads were riding around on racing bikes. Talking about stressing the plastic….
Holding big rods off the back of the boat made more sense.
While a layperson, I was a PA with a group of urologists for five years.
The PSA test, DRE, and possible ultrasond and biopsy are not useless tests. They do prevent prostate cancer deaths. They are objective diagnostic tests, instead of one guessing with, say, a mental disorder.
However, are these tests over-utilized? Yes. Absolutely. A mildly elevated PSA does not mean you have to work up the patient to rule out prostate ca. Nor should hematuria mean that you have to do a cystoscopy on such a person. Doctors, at times, have an affinity for money, and this clouds their judgement, unfortunately.
Also, with prostate cancer, it is very slow growing. An eighty year old man with an elevated PSA or prostate cancer in fact, likely does not need to be treated. It’s a ‘watch and wait’ thing.
Some this week have concluded that the risks of a simple PSA blood test outweigh the benefits. That simply is not true. Aggressive work ups regarding this issue when not necessary is where the risk exists.
[...] have written before about the uselessness of screening for prostate cancer in the past, which brought on the vitriole [...]
[...] have written before about the uselessness of screening for prostate cancer in the past, which brought on the vitriole [...]
thank you for posting this.
people should be aware of these new findings, as to weigh their options more.
after the tests, i wonder when its is a “wait and see thing” and when it’s “let’s go for treatment” thing?
I am asking all of my friends (and friends of friends) to help me support a child cancer foundation that I really believe in.
It is a facebook contest at http://bit.ly/crkrEE and the name of the foundation is called The Seany Foundation (their site is at http://www.theseanyfoundation.org/).
Seany died of Ewing’s Sarcoma cancer a few years ago and he was a teenager. I knew Seany and promised his family I would help where I could. Chase Bank is having a charity contest ending in about 6 days and if you could VOTE (it is free to vote) with your facebook account AND post it to your facebook wall, I would really, really appreciate it. http://bit.ly/crkrEE