This article is more than 5 years old. Information may no longer be current.
Foolishness in medicine: Ignoring cigarette smoking, obesity in favor of prostate cancer screening
Click Here to Manage Email Alerts
It is generally unwise to start a lecture with an apology, but as this one is an editorial, I do wish to apologize for perhaps preaching to excess.
That said, I confess that I continue to shake my head over the poor decisions of (apparently) many of my colleagues in our cherished profession.
I am proud of being a physician and oncologist with decades of experience. I also believe I was trained to make evidence-based and value-focused medical decisions — even before this approach was in fashion — in my early training more than 30 years ago by my internal medicine mentors, John Sands, FRACP;John Greenaway, FRACP, and others in Australia; and then by my oncology role models, Martin Tattersall, MD;Richard Fox, MBBS, PhD;Tim McElwain, MBBS;Sir Michael Peckham, MD; and Munro Neville, MBBS, DSc, in Australia and the United Kingdom.
Lack of evidence
I imagine you are wondering, “Where is he going with this?”
An article in this issue of HemOnc Today that really caught my attention was the report of the excellent study from Drazer and colleagues at University of Chicago that addresses the persistence of irrational prostate screening, despite encyclicals from most of the learned bodies that have any knowledge of this disease. Another article in this issue reports on a study by Sammon and colleagues, which showed that PSA screening rates have fallen, but not in the group aged older than 75 years!
I confess to a conflict of interest, as I have questioned for decades the lack of a strong evidence base to justify the profligate expenditure on thoughtless screening for prostate cancer. When randomized trials conducted by Andriole and colleagues and Schroder and colleagues failed to show an OS benefit, and one randomized trial by Hugosson and colleagues did not report OS, it was clear to me that Pandora’s box had once and for all been opened for the pro-screening lobby group.
In fact, one of the investigative teams has done regular updates of their study looking for an OS benefit, an obvious statistical rookie error. More surprising is that their multiple reports have been published in very strong journals.
Notwithstanding all the famous movie stars, generals, religious leaders and politicians who had called for routine screening — based on their years of medical training and a PSA that identified some type of prostate cancer — it seemed likely that our august profession would respond dramatically to this lack of evidence. In addition, there was a gradually increasing recognition that expenditure without return in health care is crippling our nation financially. Thus, it seemed logical that we would change direction on prostate screening.
Initially, the U.S. Preventive Services Task Force (USPSTF) issued a confusing and somewhat flawed statement, correctly addressing the lack of evidence in white males with no family history and no symptoms, but ignoring the absence of evidence for black men and men with a positive family history. Despite the flaws and ensuing confusion, they made the fair point that there is a substantial lack of evidence to support routine prostate screening.
All of this is hardly surprising, given the heterogeneity of prostate cancer, the prevalence of a rather benign variant of the disease that is increasingly regarded as not life threatening, the lack of specificity of elevated PSA and the well-documented potential harms of treatment.
Taking responsibility
Close upon the heels of the USPSTF, the learned professional societies climbed aboard the bandwagon and issued their own position papers counseling against random screening for prostate cancer.
The ASCO Value in Cancer Care Task Force included prostate screening in men with limited life expectancy in its list of recommendations for avoidance in the ABIM Foundation’s Choosing Wisely campaign. Even the American Urological Association, with its own set of conflicts of interest, eventually acknowledged the limitations of screening, and the importance of choosing the “right” patients for this expensive and relatively low-yield approach.
There was an apparent consensus that the rhetoric associated with the claim that “I was saved by a PSA test” did not necessarily translate into any type of community benefit and — in the elderly and infirm, in particular — could translate into actual harm.
Thus, it is quite disheartening to see the report from Drazer and colleagues. The bottom line is that many of our colleagues continue to screen the elderly and infirm, ignoring evidence and recommendations from the colleges and leaders in the field.
It is clear that many of our colleagues have changed direction, and screening rates have clearly decreased somewhat. However, more than 1.4 million men aged 65 years or older with a greater than 50% predicted chance of death within 9 years were screened. More extraordinary to me is that the researchers’ tables suggest that many of these individuals also were active smokers and overweight, two factors which, if addressed meaningfully by the patients and their physician advisers, actually could contribute to improved OS. In their parallel study, Sammon and his colleagues have shown that national screening rates have not reduced in the elderly, the group known to be disadvantaged by this process.
Of course, there will always be the occasional zealot who refuses to be influenced by level one evidence and who uses inflammatory rhetoric to convince the masses that screening should be continued unabated. Surely we need to consider the nature of opinions being expressed, and the absence of real evidence to back them up!
This may be one instance where the health insurance industry may have to take a more draconian role — this time in a more useful fashion than is often the case — by questioning reimbursement on a routine basis for patients who do not fall within the nationally recommended parameters.
I actually hate that idea, but the University of Chicago data suggest that our profession is failing to police itself adequately in this area, and someone has to take responsibility.
References:
Andriole GL, et al. N Engl J Med. 2009;doi:10.1056/NEJMoa0810696.
Drazer MW, et al. J Clin Oncol. 2015;doi:10.1200/JCO.2015.61.6532.
Hugosson J, et al. Lancet Oncol. 2010; doi:10.1016/S1470-2045(10)70146-7.
Raghavan D. Eur J Cancer. 1997;33:329-330.
Raghavan D. Cleve Clin J Med. 2008;75: 33-34.
Raghavan D. Mayo Clin Proc. 2013;doi:10.1016/j.mayocp.2012.11.004.
Sammon JD, et al. JAMA. 2015;doi:10.1001/jama.2015.7273.
Schröder FH, et al. N Engl J Med. 2009;doi:10.1056/NEJMoa0810084.
For more information:
Derek Raghavan, MD, PhD, FACP, FRACP, FASCO, is HemOnc Today’s Chief Medical Editor for Oncology. He also is president of Levine Cancer Institute at Carolinas HealthCare System. He can be reached at derek.raghavan@carolinashealthcare.org.
Disclosure: Raghavan reports no relevant financial disclosures.