Don't Punish Doctors for Ordering PSA Tests

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A recent op-ed urges federal Medicare officials to not penalize doctors for ordering the prostate-specific antigen cancer screening test, which may seem like an odd sentiment to endorse, given that the American Council on Science and Health has stated that these tests are being given too often (such as here and here.)

Dr. H. Gilbert Welch, professor of medicine at Dartmouth, and Dr. Peter C. Albertsen, (a urologist) also has to feel just as strange in asking to not penalize doctors for providing it, since he has written often about the unintended, adverse effects of too much screening: overdiagnosis and over-treatment.

A little background is in order. When the prostate-specific antigen, or PSA, test became available in the late 1980s, it appeared to be a major advance in the fight against prostate cancer (prca). A simple blood test made possible early detection of prca, and this would presumably lead to a reduction in the toll of the cancer. Within a few years, the PSA test became the standard of care for men.

What followed was predictable a ballooning of the number of prca diagnoses due to a steep increase in prostate biopsies done on men with elevated PSA levels. However, subsequent studies have clearly shown that the ability of the PSA test to reliably predict cancers that would be amenable to curative surgical removal was poor, at best.

This was due, in most part, to many false positive results, which led to over a million needless surgeries, specifically, prostate removals which often leave men incontinent and/or impotent, while providing no benefit. The reason, we now know, is because many men have small foci of prca which would never have been detected, or caused any harm, in the absence of the PSA test. In 2012, the United States Preventive Services Task Force, issued its final recommendations: routine PSA screening should not be done.

In November 2015, a proposal under consideration by Center for Medicare and Medicaid Services (CMMS), the governing body of both programs would penalize doctors who ordered routine PSA tests for their patients, presumably as part of a federal effort to improve quality versus cost in health-care services.

Drs. Welch and Albertsen, the authors of the New York Times op-ed, believe this would be a bad move, for a variety of reasons, noted above, plus the question, "Well, if PSAs are not helpful, indeed harmful, and costly, why not target doctors who order them?" The answer is that instead rewarding doctors for not ordering a test that might help some patients is worse policy, and interferes with patient-doctor autonomy in clinical decision-making.

Furthermore, identifying doctors who order PSAs as "bad doctors" is counterproductive and inappropriate. Invoking a cost savings rationale plays into the hands of those who reject any attempt to restrict screening: they merely decry such restrictions as a government attempt to save money by allowing more men (or women in the case of mammography) to die of cancer. But in fact, reducing needless screening is a medical issue, not a financial one, since it prevents the adverse effects of needless surgery. Screening saves patients from undergoing procedures that have adverse effects, which can sometimes be lethal, and for no potential benefit.

The case against prostate cancer screening is strong. PSAs detect plenty of indolent, non-threatening cancers, which when found often lead the patient to extensive surgery, which will not really save nor extend the patient's life, but rather do the opposite: over half of men over age 60 have these small cancer foci. These should be left alone.

Our own co-founder and former president, the late Dr. Elizabeth M. Whelan, who passed away in September 2014, originated the "bird-rabbit-turtle" analogy they used in their article in her letter to the editor of the New York Times in January 2002, entitled "Is cancer testing worthwhile?"