Nuance is not a commonly cited virtue of American discourse, as you well know if you’ve watched reality television of late, or, for that matter, any recent political debate. And that’s what makes me nervous about the recent decision by the U.S. Preventive Services Task Force (USPSTF) to recommend against routine screening for prostate cancer using prostate-specific antigen levels.
I’m neither a physician nor a biostatistician; rest assured, I won’t argue the science here. But I do worry about the psychological implications of a Grade D recommendation (considered "at least fair" evidence) that screening does more harm to men than good.
The task force’s report, published online May 21 in Annals of Internal Medicine (annals.org), makes some excellent points about the need for more reliable screening measures and real quality-of-life costs associated with false positive PSA results and aggressive treatment of what is, in many cases but not all, a slow-growing disease.
Its call for better research deserves special mention. Prostate cancer, in my opinion, has long been a neglected step-brother in cancer research funding, despite the fact that it kills more American men than does any other cancer, except lung cancer. Just because I was curious, I compared this week the number of hits on PubMed for the search terms "prostate cancer" and "screening" versus "breast cancer" and "screening." To be sure, it’s a crude measure of relative attention, but the disparate tally was striking: 55,758 to 129,451.
The task force report also offers physicians a brief, handy guide on how to talk with patients about the latest findings, including three generic "patient scenarios." I think that’s fine, as far as it goes, but what the guide fails to capture is the nuance of American attitudes toward screening, toward medicine in general (and especially large, impersonal task forces known by their acronyms), toward preventive health care, and toward prostate cancer itself.
It will be those attitudes physicians will encounter once patients, their partners, and families hear the recommendations in a 12-second sound bite, while channel-flipping on their way to an update on the Kardashian family.
There will be patients, I suspect, who will completely disregard the recommendations; a few, perhaps, because they’ve read of the scientific objections of many dubious urologists.
More, undoubtedly, will suspect a conspiracy between medicine and insurance companies bent on depriving patients of life-saving treatment in the interest of saving a few bucks.
Others won’t hear the word "screening," and will refuse to see the doctor when they suffer dysuria, hematuria, or pain, telling their annoying wives they heard on the news there’s no point in getting a test for that.
Some patients will insist on the PSA every year beginning in their 30s and will press for a biopsy if their numbers wobble a bit from year to year – a strategy they would have pursued regardless of recommendations to the contrary today, tomorrow, or in 10 years.
Unfortunately, black men will hear the news and may resist getting a PSA even in the face of a family history of prostate cancer and the deplorable under-representation of African American men in the studies on which the recommendation was made. (Just 4% of men enrolled in the U.S. Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (N. Engl. J. Med. 2009;360:1310-9) were non-Hispanic blacks; the ethnicity of those in the other trials wasn’t even reported, despite the fact that black men die of prostate cancer at a rate double that of white men.)
More than a few individuals will consider the recommendations against the backdrop of evidence that scientists call "anecdote" and regular folks call "Uncle Bill." If he died at 74, ravaged by bone pain, there’s a good bet that the nephews in the family will still be urging the doctor to check the box on the lab slip marked "PSA." If, on the other hand, Albert down the street had prostate surgery, and never regained the ability to urinate normally (or have an erection, it might be whispered), the new recommendations might be welcomed just fine.
My point is, the press conferences and headlines that trumpet controversial new cancer guidelines come and go, the acronym-laced logos repacked into boxes and the microphone cords looped into their cases. But the aftershocks ripple for months, as physicians in their small offices try to weigh in with their own beliefs and experiences, as they manage the fear, denial, and doubt that the patients bring in on their own.
Cost matters. Risks and benefits must be given appropriate weight. Medicine is, today as always, a journey negotiated in the partial fog of unknowns.