Alan Cassels guest blog post: PSA test – good myths die hard

Alan Cassels, who is a pharmaceutical policy researcher at the University of Victoria, British Columbia,  a journalist, and author of the books  “Seeking Sickness” and “The ABCs of Disease Mongering”,  sent in this unsolicited guest blog post.  Soon, we hope to solicit more pieces from Cassels.

Matthew Tully wrote on the Indy Star website on December 16^th, 2014  that “Cancer screening may have saved former deputy mayor’s life.”

How true he could be.

Find cancer early. Get treated. Live long and prosper.  That’s the narrative that unfolds in this heartwarming piece about the lifesaving qualities of the Prostate Specific Antigen (PSA) test.

This narrative could be true, that the likable, energetic Mike O’Connor, 51,  a former chief deputy mayor of Indianapolis had his life saved from a  PSA test.  Maybe they caught the cancer early and maybe he’s going to benefit from the early treatment for prostate cancer. But on the other hand, it could be false.  I’d bet on the false.

So would, I think, most men if they understood the odds which underlie the maxim of prostate cancer:  most men will die with it, but not because of it.  Millions of men in the US have been turned from healthy middle-aged men into “prostate cancer survivors” due to a check mark on a lab request sent in by their doctors.    A simple blood test that unleashes a cascade of interventions, worry and medical activity.

Tully’s opinion piece acknowledges a ‘raging debate’ over the value of the PSA test,  yet increasingly there’s no debate:  the test’s many problems led to it being given the dreaded “thumbs down” award by the US Preventive Services Task Force in 2012.  Unconflicted experts who look closely at the science conclude that, unlike its ‘lifesaving’ veneer, the best meta-analysis of PSA screening says that it doesn’t save lives and adds nothing to the quality of life. The NNS (number needed to screen) has been calculated that to save one life you have to screen 1,410 men, clearly a low yield, considering that the collateral damage along the way are many men left incontinent, impotent or otherwise injured from treatment for something that would never have gone on to hurt them.

The fact that the urologists have a huge vested interest in keeping up the parade of PSA-positive men to their doors for prostate treatment means that these kinds of opinion columns and stories will continue to be produced, and the test, called the “Poster Child for Overdiagnosis” will continue to be offered to men.

There is one incontrovertible fact in this story:  That prostate cancer kills about 30,000 men a year.  Everyone wishes there was a better test, but instead of dumping on the USPSTF and disagreeing with their evidence-based assessment of the test perhaps the urologists could admit that this test is a dud and that they need to find a better way to save lives that doesn’t inflict so much unnecessary suffering on the population.

This opinion piece – written by a journalist – doesn’t advance our knowledge, but exposes the men of Indianapolis to the usual myths of the narrative:  the celebrity factor, the ‘it saved my life’ factor, and the burying of the conflicts of interest among the urologists who are still clinging to hope that stories like this will help the PSA survive and thrive.

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Gary Schwitzer comments:

Matthew Tully is a political columnist for the Indianapolis Star.  Granted, what he wrote that caught Alan Cassels’ eye was an opinion column.  But it’s an opinion column written by a newspaper’s reporter published by that same newspaper.  Journalists are supposed to independently vet claims.  Those who write opinion columns often do not.  Should reporters be allowed to publish opinion pieces in the newspaper they work for?

Here’s what we got in this column:

• The reporter described his wife’s co-worker (at least he disclosed this) this way: “What he wanted to discuss was his frustration that too many men aren’t getting PSA screenings, the basic blood test that first raised red flags in his case, because influential governmental and medical organizations now discourage them. “A good number of people you and I know,” he said, “are going to suffer much more dramatic consequences due to something that could have been fixed moderately easily.”
• The journalist took that quote, and added to it a quote from a conflicted urologist, who said, “To be frank, I think it’s a travesty. I hope they will revisit this recommendation and ultimately reverse it.”
• No independent perspective appears in the column.  We are told that “Many urologists agree and have sharp words for the federal task force recommendations.”  But we do  not hear from any primary care physician, nor from any member of the USPSTF, nor from anyone (of whom there are many in medicine) who agrees with the concerns about the PSA test.
• I’m pleased for Mr. O’Connor that he’s pleased with his outcome.  There are many stories that can be told about men who are not happy with the outcomes of their PSA test – men who wish, in fact, that they’d never rolled up their sleeve for that supposedly “simple blood test.”  Those perspectives are missing in this opinion column. That makes it an almost predictable opinion column that “doesn’t advance our knowledge,” as Cassels wrote.  And that makes it an even more questionable thing for a newspaper to allow one of its reporters to publish – opinion or news or whatever you want to call it.

Addendum published less than an hour after the original post was published:

Urologist Benjamin Davies wrote on Twitter that I must be “certain all urologists are conflicted.”  That’s not true, and I think he knows it.  He, for one, has published many thoughtful unconflicted pieces about prostate disease and other urology issues.  One that I know he likes is this:  http://www.forbes.com/sites/matthewherper/2014/07/17/in-defense-of-prostate-cancer-screening/

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