The New Health Dialogue

In light of the media discussion surrounding PSA testing at the moment, Health Dialog (a producer of patient decision aids for medical decisions) is making their PSA test decision aid available free of charge on their website. The decision aid includes video, booklet, and web-based formats, and presents the evidence about the risks and benefits of PSA testing impartially. If you are a man considering having a PSA test, the decision aid may help you come to an informed decision.

The medical blogs are on fire this week with comments about the US Preventive Services Task Force (USPSTF)'s newest recommendation on the prostate specific antigen (PSA) test. On the basis of the latest scientific data, the task force is now recommending against PSA screening. An earlier recommendation said that routine screening was unnecessary in men over 75, or those with life expectancy shorter than 10 years; the update will recommend against routine PSA testing for any man of any age.*

Not surprisingly, this has set off an angry howl from many pro-PSA patient advocacy groups, some physicians, and battalions of outraged men, many of whom gave personal testimonials to the effect that the PSA test saved their lives. In the words of one Bruce Rogers, from Champain, Ill., "Were it not for the PSA tests, today I would be dead and buried."

Of course, all the men who have died from the treatment for prostate cancer or are too sick or debilitated to get to their keyboards aren't able to tell their side of the story, and whether or not the test actually saves lives is at best debatable. (You can read about the evidence for and against the test in a story that will appear in this Sunday's New York Times Magazine.)

The other common reaction to the new task force recommendation was expressed by a fellow calling himself "whoami2day," who wrote in response to a CNN story:

"Here we go again. OUR government in the pockets of the insurance companies and oil companies. How much longer are we going to put up with this crap.  . . . "

In other words, the task force's recommendation is all about saving the government money by denying men a test that could save their lives. Whoami2day is right that the debate over PSA testing is partly about money, but he may be targeting the wrong villain.

Nearly $10 billion was spent on prostate cancer treatment in the U.S. in 2006, according to the latest figures from the National Cancer Institute. That amount does not include the costs of PSA screening, or of helping patients cope with the downstream side effects of their treatment. Hospitals, drug and device manufacturers, even Kimberly-Clark, which makes adult diapers, all benefit from the large numbers of patients that PSA testing produces. The marketing departments of many hospitals openly admit that they offer free PSA testing as a loss leader, a means of bringing in new (paying) customers.  Many urologists depend on surgical prostate removal as their main source of income. According to Dr. Otis Brawley, chief medical officer of the American Cancer Society, some physicians have openly complained that any criticism of PSA testing could hurt their wallets by cutting down on the number of patients diagnosed.

Manufacturers spend millions of dollars providing support for patient advocacy groups that promote screening.  Us TOO, Man to Man and other groups, which are heavily funded by industry, hire celebrities like Joe Torre, Colin Powell and Robert deNiro, who testify that their lives were saved by the PSA test. Groups sponsor free testing in malls and grocery store parking lots. They buy television ads, and banners at sporting events and race tracks that encourage men to  “man up,” and “know your numbers.”

The barrage of public service announcements and free screenings exert a powerful effect on public perception. During a U.S. House oversight hearing, the widow of Congressman Dean Gallo, who died of prostate cancer at age 58, said that she wanted to "scratch the eyeballs out" of men who don't get tested . . .

The controversy over the task force recommendations is not a clash between heartless regulators, hoping to save a buck by risking men’s lives, and noble patient advocates and defenders of the sick. It's more a matter of the message of true believers in screening being amplified by big money.

*This blog’s stance on PSA testing is well established: there evidence to suggest that the test saves lives is weak, and it leads to risky follow-up procedures. For more on the evidence behind the task force recommendation, see our post here or this week’s New York Times Magazine story here.