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Flat Earth, anti-Darwinism, the myth of global warming and PSA testing
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There have always been people of great resolve who have been absolutely certain of what they know, without necessarily having had to prove it.
There is not much point in producing a long list, but you will get the picture if I give just a few examples.
There were (are?) those who believed the Earth to be flat, and that it was too risky to test their hypothesis because of the risk of falling off the edge. Then there have been the anti-evolutionists, who decried purportedly bogus Darwinian data, such as fossil and skeletal remains, and homologous patterns of gene expression between different species.
Even today, we have a bunch of politicians, radio hosts and assorted zealots — in Australia, we used to call them “nutters” — who variously view global warming as fake evidence, a Chinese plot or manipulation from one of the U.S. political parties. Somehow they have been able to ignore the polar villages that have been drowned by the rising seas, the melting arctic and Antarctic ice caps, and actual temperature measurements and weather changes.
The latest medical equivalent of this folly is the renewed debate on screening for prostate cancer. This has been covered in such detail — and so often — that it is embarrassing to have to address it in these pages again. However, once again, I have serious concerns about the irrationality on both sides of the argument, and feel great concern that the hapless general clinician — and the community at large — must again be struggling with confusion on this issue.
What we know
Just to remind everyone, here are a series of facts (not fake news):
- Prostate cancer is common in our community, particularly in aging men;
- It presents with two extreme patterns — well-differentiated, relatively benign disease and high-grade, potentially life-threatening malignancy. The problem is that we are not very good at predicting which patients have which type, and there is an intermediate form that is somewhat unpredictable. PSA screening primarily detects the less aggressive type, which is much more common;
- Digital rectal examination of the prostate is unreliable for the detection of early prostate cancer;
- Interventions for diagnosis and treatment of PSA–detected prostate cancer can include significant morbidity and even occasional mortality;
- Some population studies have shown the existence of prostate cancer in more than 50% of the male population older than 70 years, yet a much smaller proportion actually succumb to this disease;
- There has not been a significant reduction in deaths of prostate cancer since the introduction of PSA screening, particularly when one considers the vast numbers of subjects entered into various screening programs;
- PSA is a useful test, but not completely specific as it can be produced by prostate cancer, benign prostate hyperplasia — common in older men — and a range of other infections and inflammations of the prostate;
- Given the large proportion of patients identified with low-risk disease or benign prostate hyperplasia, a new standard introduced into the community is the policy of watchful waiting. This consists of repeated visits, examinations, screening PSAs and anxiety production among patients, but with maintenance of the old revenue stream at great cost to the community; and
- Several large randomized trials of PSA screening for prostate cancer have been carried out. Many of them have substantial flaws. Two have shown improvements in the rate of deaths caused by prostate cancer, but none have shown an improvement in OS. None of these studies has addressed the outcomes in black men or in those with family history of the disease.
New screening recommendations
So why another editorial on this topic?
Our good friends at the U.S. Preventive Services Task Force (USPSTF) have burst into print again to announce they have reconsidered their encyclical on prostate screening. Having previously given it the thumbs-down, task force members — apparently based on the published data — have now modified their stance. They have informed us that men aged 50 to 75 years should discuss screening with their physicians, that it still doesn’t work for men older than 75 years, and that there are no data to allow comment for men who are black or have a family history.
It may be that they have fallen prey to uninformed political pressure. Frankly, I view this whole deal as outrageous, as most of their present view was obvious to anyone with any competence to read the published data. Gentler commentators have applauded them for having nearly come to the right conclusion based on the available data. However, my view is there are no convincing new data, and after years of contributing confusion, the task force has now come closer to an accurate representation of the published information.
The best the task force has been able to produce is that men should discuss this issue with their physicians. It has backed down from its earlier recommendations that, in effect, included blacks and men with a family history, but it had no data to support this in the first place.
Given that the Environmental Protection Agency seems to be moving its stance on global warming to reflect the extant lack of political wisdom, I have little hope that the USPSTF will be disbanded by any government ... what a waste of taxpayer dollars!
Testing of elderly men
Sadly, two august bodies representing some of the clinicians involved in the management of urological malignancy — the Society of Urologic Oncology (SUO), to which I still pay dues, and the American Urological Association (AUA) — issued press releases noting the improvement in the USPSTF position, namely the softening of the stance to require discussion in younger patients.
However, these groups continue to argue for consideration of screening in the elderly.
Once again, I just shake my head. Like the Flat Earth Society and the anti-evolutionists, do these good people not understand the import of published data?
In the European study, so celebrated in urological circles, patients aged older than 75 years actually had a worse outcome — including survival — from being screened. None of the published studies has shown an OS benefit, so one must presume that the lives saved from prostate cancer deaths in the population randomly assigned screening have been lost to other causes. Wouldn’t it make sense to address this before recommending renewed attack on the elderly?
I don’t disagree with the logic that underpins the AUA and SUO positions regarding the increased longevity and fitness of older men in the present era. However, my concern is that they continue to advocate an approach that remains expensive and unproven, doggedly sticking to their guns without supporting data, and potentially wasting money and harming older men who actually deserve better treatment.
Although it is perfectly appropriate for asymptomatic men to discuss any condition of concern with their physicians, why do we need the expensive USPSTF to tell us that?
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.