Cassels is a drug policy researcher. He frequently reports on consumer drug issues and has authored and co-authored several books. He tweets as @AKECassels.
The major health news story last week was on a re-assessment of prostate cancer screening published in the Annals of Internal Medicine. The study’s release generated stories in the New York Times, TIME, Consumer Reports, STAT, ABS-CBN News (Philippines) and the LA Times, among others.
The reporting confirms what we already know about the PSA test — that it involves trade-offs including financial costs and long-term harms from screening in exchange for what appears to be very few numbers of lives saved. It is in knowing and understanding these trade-offs that men can be sure that they are going into a PSA test with their eyes wide open.
According to the American Cancer Society, in 2014 (the most recent data available) 28,343 men in the United States died from prostate cancer. As the second leading cause of cancer death in men, examining and re-examining a test that might prevent those deaths never fails to generate headlines. The PSA test has, over time, become more closely dissected and debated than many screening tests, which is a good thing, seeing as it’s offered to otherwise healthy people (and thus possesses the potential to make those people less healthy via harms of over-treatment.)
Prostate cancer screening is not a new topic to HealthNewsReview.org. We’ve discussed mass prostate cancer screening events, the problem of using anecdotes, and praised high quality reporting of a study of treating vs. not treating prostate cancer patients. In this recent batch of headlines on the Annals of Internal Medicine study, there are enthusiasts and detractors on the “significance” of the new findings, and overall the coverage gets a pretty good passing grade. Some stories drilled down into the problems with this type of research and why it is difficult to draw firm conclusions.
What kind of study was it? In this case, it was a mathematical modeling study parsing out what happens when men randomized to be in the “non-screened” group don’t follow instructions and get screened anyway, and how this affects the interpretation of results. Few stories commented on this aspect of the study except the New York Times which quoted Kenneth Lin, MD saying that “results from models are less convincing than data from actual clinical trials.”
What other factors could be in play? The STAT article mentioned what is known as the presence of “healthy user bias,” which is often overlooked when examining two groups (for example, drug takers versus non-drug-takers and screened men versus non-screened men). Basically, this means that those who choose to undergo screening or treatments might be a healthier cohort of patients at the start. Having better health introduces a bias that may not be accounted for when there are differences between groups.
Did the journalists follow the money? None of these stories reminded us about how big the PSA enterprise is. We need to be reminded of the costs of PSA screening programs and the great bolus of medical services they can generate, including more biopsies, tests, drug therapies, surgeries, hospital time, and the impact on the patient’s earning power as he’s recovering. Urologists make a significant amount of their income from treating the results of PSA tests. We found Etzioni, the lead researcher of this study, does have a potential financial conflict (which was disclosed in the study) but which was not mentioned in any of the stories we reviewed. (In HealthNewsReview.org’s systematic reviews of the Los Angeles Times and STAT News stories, reviewers pointed out that neither story raised the issue of financial conflicts.)
What is the bottom line for the patient? Lots of expert commentary might be enlightening for some, but aggravating for others. At the end of the day a news story should lay out in clear terms the benefits for men who undergo PSA testing, as well as the not inconsequential trade-offs. This infographic produced by the US Preventative Services Task Force lays out the benefits and risks in simple terms.
How long will you survive if you have prostate cancer? Cancer.net reports statistics on 5-year survival rates related to prostate cancer, and states that “The 5-year survival rate for most men with local or regional prostate cancer is almost 100%. Ninety-eight percent (98%) are alive after 10 years, and 96% live for at least 15 years. For men diagnosed with prostate cancer that has spread to other parts of the body, the 5-year survival rate is 29%.”
Last tip: Should we avoid using the term “life-saving” when we really mean “death-delaying?” No drug or screening program has ever saved a life. At best, it has delayed a type of death.