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The prostate screening gamble

The Preventative Services Task Force stirred up some controversy this week, when it recommended that healthy men no longer receive a PSA blood test to screen for cancer. According to the Task Force, the test does not save lives and leads to unnecessary tests and treatment that can cause more health problems.

During Tuesday’s presidential debate, Newt Gingrich used the task force recommendation to revive the consistently debunked “death panels” meme:

I was just swapping e-mails today with Andy von Eschenbach [head of the National Cancer Institute under George W. Bush]. And he wrote me to point out that the most recent U.S. government intervention on whether or not to have prostate testing is basically going to kill people. So, if you ask me, do I want some Washington bureaucrat to create a class action decision which affects every American’s last two years of life, not ever.

I think it is a disaster. I think, candidly, Governor Palin got attacked unfairly for describing what would, in effect, be death panels.

In his answer, Gingrich presents what The New Republic’s Jonathan Cohn calls a “grossly one-sided view of the debate over prostate screening.” The reality of course is more complicated, as the New York Times points out:

The P.S.A. test, routinely given to men 50 and older, measures a protein — prostate-specific antigen — that is released by prostate cells, and there is little doubt that it helps identify the presence of cancerous cells in the prostate. But a vast majority of men with such cells never suffer ill effects because their cancer is usually slow-growing. Even for men who do have fast-growing cancer, the P.S.A. test may not save them since there is no proven benefit to earlier treatment of such invasive disease.

As the P.S.A. test has grown in popularity, the devastating consequences of the biopsies and treatments that often flow from the test have become increasingly apparent. From 1986 through 2005, one million men received surgery, radiation therapy or both who would not have been treated without a P.S.A. test, according to the task force. Among them, at least 5,000 died soon after surgery and 10,000 to 70,000 suffered serious complications. Half had persistent blood in their semen, and 200,000 to 300,000 suffered impotence, incontinence or both. As a result of these complications, Richard J. Ablin, who in 1970 discovered a prostate-specific antigen, has called its widespread use a “public health disaster.”

H. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, and co-author of Overdiagnosed: Making People Sick in the Pursuit of Healthcompares prostate screening to gambling: “There are winners and there are losers. And while the few winners win big, there are a lot more losers.”

David Newman, a researcher at Mount Sinai hospital in New York, puts it even more bluntly:

Imagine you are one of 100 men in a room,” he says. “Seventeen of you will be diagnosed with prostate cancer, and three are destined to die from it. But nobody knows which ones.” Now imagine there is a man wearing a white coat on the other side of the door. In his hand are 17 pills, one of which will save the life of one of the men with prostate cancer. “You’d probably want to invite him into the room to deliver the pill, wouldn’t you?” Newman says.

Statistics for the effects of P.S.A. testing are often represented this way — only in terms of possible benefit. But Newman says that to completely convey the P.S.A. screening story, you have to extend the metaphor. After handing out the pills, the man in the white coat randomly shoots one of the 17 men dead. Then he shoots 10 more in the groin, leaving them impotent or incontinent.

Newman pauses. “Now would you open that door?”

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