PSA debate is part of trend toward less screening
Fewer tests are advised for well people
Many men were surprised last week when a government advisory panel recommended that doctors stop using the PSA test to screen healthy men for prostate cancer.
Yet experts say the recommendations by the U.S. Preventive Services Task Force are a part of a broader trend that has been building for years. People are taking a closer look not just at cancer screenings but at all medical interventions, says Steven Woloshin, co-director of the Center for Medicine and the Media at the Dartmouth Institute for Health Policy and Clinical Practice. Concern is growing because of doctors’ recognition of their risks and side effects.
“There is something going on, not just in cancer,” Woloshin says. “It’s encouraging. It feels like this is the beginning of a sea change in attitudes toward testing, treating and overdiagnosis.” Doctors are taking a “less is more” approach on several fronts: Last month, nine physicians’ groups launched the “Choosing Wisely” campaign to
“We didn’t realize we would cause thousands of men to become impotent.”
Peter Bach, Memorial Sloan-kettering’s Center for Health Policy and Outcomes
discourage 45 overused tests and procedures, such as stress tests during routine annual exams. Many overused tests involve trying to “help the well stay well by looking for things to be wrong,” says H. Gilbert Welch, a physician and coauthor of Overdiagnosed: Making People Sick in the Pursuit of Health.
The American College of Radiology also is leading campaigns to reduce unnecessary exposure to medical radiation, which has been estimated to cause up to 29,000 cancers a year. Researchers estimate that one-third of CT scans may be unnecessary, according to a 2009 report in Archives in Internal Medicine.
And in the past four years, medical groups have voted to restrict several types of many cancer screenings.
-In 2008, the task force rec- ommended limiting the PSA screening to men under age 75, reasoning that older men probably would not be helped by a test that largely detects slowgrowing cancers.
-In 2009, the task force recommended against routine mammograms for women under 50. That recommendation drew fierce protests from many women, radiologists and many politicians.
-In March, in a less controversial move, the American Cancer Society revised its recommendations for cervical cancer, suggesting that women get screened every three to five years instead of every year, a change that reflects the slowgrowing nature of those tumors.
-Last week, medical groups endorsed using CT scans to screen for lung cancer for the first time, but only in a very specific group: smokers and exsmokers ages 55 to 74 who smoked the equivalent of a pack a day for 30 years and smoked within the past 15 years.
When writing guidelines for a new technology such as CT lung cancer scans, it’s important to avoid repeating past mistakes, says Peter Bach, director of Memorial Sloan-kettering’s Center for Health Policy and Outcomes. The PSA was approved in 1986 to monitor patients with diagnosed prostate cancer and in 1994 to screen healthy men — before researchers had determined whether the tests improved survival, Bach says. For years, many medical groups recommended the PSA for all men over 50. “The PSA test was unleashed on the male population without any evidence that it provides any benefit and without any quantification of the potential harm,” Bach says. “We didn’t realize we would cause thousands of men to become impotent.”
Convincing people that they could be better off with fewer screenings could be a tough sell, Woloshin says. But Welch, the physician and author, agrees that the tide is turning. There’s a growing recognition that “when you are dealing with well people, the balance is really fine: It’s hard to make a well person better, but it isn’t hard to make them worse,” Welch says. “We need to have really high thresholds before we start doing things to well people.”