“This is Prostate Cancer Awareness Month, but it feels more like Prostate Cancer Propaganda Month,” Joel Keehn, senior editor at Consumer Reports Health.Org observed in a recent phone conversation.
Consumer Reports Health.Org has posted an excellent piece on why deciding to have a PSA test to detect early-stage prostate cancer is not a slam-dunk decision. We just don’t have any medical evidence that the test saves lives—or even lengthens life by one day. But we do have evidence that current treatments can lead to life-changing side-effects. See the post here.
Meanwhile those who profit from prostate cancer treatments are taking full advantage of “Prostate Cancer Awareness Month.” On the post, Keehn notes that “during this year’s U.S. Tennis Open the former tennis star John McEnroe has been promoting prostate-cancer screening for men as young as age 40, citing new recommendations from the American Urological Association.” (No surprise, the urologists who administer the tests and treatments endorse them.) “But during his appearances on CNN’s Larry King Live and the Early Show on CBS, there’s been no mention that most organizations, including the American Cancer Society and the United States Preventive Services Task Force” no longer recommend routine testing.They “emphasize that the evidence for the test is sketchy,” Keehen writes. “As a result, those organizations say that men should discuss the pros and cons of the test with their doctor.
“Nor was it mentioned that McEnroe was being paid for his efforts by the pharmaceutical giant GlaxoSmithKline,” Keehn adds, “which just happens to make dutasteride (Avodart), a prostate medication that GSK hopes may be used as a prostate-cancer prevention drug. And the Web site he promotes during those appearances, no surprise, is also funded by the drug maker.”For further information on treatments for prostate cancer—including “watchful waiting,” see these HealthBeat posts here and here.
Just to be clear, Avodart is aa treatment for benign prostate enlargement, not cancer. However, there is probably a marketing rationale that goes as follows: 1) Get men to worry about prostate cancer so they go to their doctor, 2) Doctor asks questions about prostate symptoms: frequent urination, getting up at night, weak stream, etc. 3) Patient amplifies minimal symptoms out of fear that cancer could be “missed”, 4) Doctor does PSA and prostate exam which are normal and he tells the patient that his “symptoms” are probably due to benign enlargement and offers prescription for Avodart, 5) Patient is greatly relieved and gratefully accepts the prescription along with a vague (inaccurate) sense that the drug will protect him from prostate cancer, particularly if (either because of placebo or genuine drug effect) his “symptoms” are reduced or go away completely.
Marc —
Good to hear from you.
Thanks for the correction on actual use of this medication.
Your analysis to how the marketing rationale works sounds spot-on.
It’s interesting to previously hear President Obama’s simplified message about overtreatment, you know the kid with the sore throat getting his tonsils out and now to read this post.
It is the institutions who advocate overtreatment, not individual physicians really. The institutions are run by business administrators who benefit from increased volume.
Then once the administrators take over, they then can get the clinical staff to support what increases volume, either through PR, advertising, job security, professional advancement, legal protection, etc. etc. The ways to manipulate are varied and seemingly not connected unless viewed together as a single minded push for increased revenue.
I invite readers to visit http://mdwhistleblower.blogspot.com/2009/07/prostate-cancer-screening-stop-psa.html
This piece generated the highest volume of comments and the most spirited comments of any posting on the entire blog. I implored my own father not to have his PSA checked, but his physician did so in any case. In my view, the PSA is a microcosm of what is wrong in medicine.
Avodart (dutasteride) is only approved to treat benign prostatic enlargement, but GSK is investigating its use in preventing prostate cancer as well, similar to the way the related drug finasteride may be used to prevent prostate cancer. See this link: http://www.auanet.org/content/press/press_releases/article.cfm?articleNo=130
Joe Says, Michael and Joel
Joe Says–I’m afraid that in Manhattan individual physicians in private practice continue to strongly recommend PSA testing– and unproven treatments for what appears to be early-stage prostate cancer.
They also recommend unnecessary angioplasties and bypasses.
Though I agree that hospitals and hospital admnistrators also try to increase value–they see themselves as revenue centers (i.e. that their job is to generate reveneues) when they should see themsleves as cost centers.
Michael– I agree that
the PSA is a symbol of what’s wrong with U.S. medicine.
PSA testing isn’t done in many other developed countries; they gave it up long ago when it became clear that there was no medical evidence that it saves lives.
I read your post on PSA testing and urge others to do so.
I would add that it’s not impossible to stop the PSA train once you’ve tested and told you have early stage prostate cancer.
Quite a few years ago, my husband was diagnosed –using a PSA test and biopsy.
He told me that the doctor planned to radiation via “seeding”.
The doctor said “if you were my father, that is what I woudl recommend.”
I suggested that my husband ask the doctor what he thought about watchful waiting instead.
My husband did that.
Big smile from doctor: “I think that’s an EXCELLENT idea.”
Had he ever mentioned watchful waiting to my husband?
No.
I said to my husband “So what happened to ‘If you were my father,”
Since then, my husbnd’s PSA levels have gone done.
He probably never had early stage prostate cancer.
Luckily, my husband is not terrified of dying and so it was not hard for me to
presaude him that watchful waiting made more sense.
If I could do that, I would think that a great many urologists could talk their patients down off the ceiling and persuade them to try “watchful waiting.”
This is an area where the shared decision-making techniques used at Dartmouth, Ottaw and at other places have been very, very successful.
Joel– Thanks for the clarification–and for your original very helpful post.
Although PSA screening eradicated advanced prostate cancer from the population, there was a downside.
According to Welch’s report in August JNCI, one million men were overdiagnosed and overtreated for prostate cancer over the last twenty years.
Why was PSA Screening for Prostate Cancer, a 20 year failed Medical Experiment ? Get the whole story here…
http://jeffreydach.com/2009/10/01/psa-testing-the-failed-medical-experiment-by-jeffrey-dach-md.aspx
Recent evidence indicates that children who are less severely affected by tonsillitis are usually not sufficiently helped by tonsillectomy to justify doing the surgery. Accordingly, it would seem prudent in most cases to limit tonsillectomy to children who meet the stringent criteria just specified.