Dartmouth Institute Op-Ed: Why Doctors Shouldn’t Be Punished for Giving Prostate Tests
By H. Gilbert Welch and Peter C. Albertsen
BOTH of us have raised serious questions about prostate cancer screening. Nevertheless, we hope Medicare chooses not to pursue a strategy of penalizing doctors for ordering prostate-specific antigen, or PSA, tests.
The case against prostate cancer screening is strong. The heterogeneity underlying cancer can be described through the metaphor of birds, rabbits and turtles. The goal of early detection is not to let any of the animals escape the barnyard and cause a cancer death. But the birds have already flown away. They are the most aggressive cancers, the ones that have already spread by the time they are detectable, the ones that are beyond cure. The rabbits, potentially lethal cancers that might benefit from treatment, are ready to hop out at any time. These are the cancers we hope to control with early detection.
Then there are the turtles — these are nonlethal cancers that aren’t going anywhere. Screening is really good at finding these cancers, and the prostate gland is full of them. Over half of men age 60 and older have small, indolent, nonlethal prostate cancers — many more than those who have harmful ones. That’s why men are much more likely to die with prostate cancer than from it.
Because doctors can’t reliably identify which cancers will become lethal, PSA screening has led a lot of men -- our 2009 estimate was over one million since the test was introduced in 1987 -- to be treated for a cancer destined to never bother them. And treatment frequently leads to impotence and can cause incontinence and bowel problems.
That magnitude of harm might be acceptable if the other cancers caught by screening were mostly those that could benefit from early detection. Unfortunately, the cancers that often kill are those that have already spread microscopically beyond the prostate before screening. Consequently, prostate cancer screening, at best, has only a small impact on the prostate cancer death rate.
Lots of people are hurt; few are helped. This is why the United States Preventive Services Task Force recommends against PSA screening.
So why aren’t we celebrating Medicare’s proposal to penalize doctors for doing the test?
One reason undoubtedly reflects our professional self-interest: The last thing doctors need is another performance measure. Patient care now requires routine interaction with an electronic medical record — an interaction that is increasingly interrupted by pop-up windows demanding some often unrelated action to proceed. These serve the dual purpose of data collection and compliance for performance measures. Patients probably do not care that doctors find these intrusions irritating and distracting, but they are often unhappy that doctors are spending more time with the computer and less with them.
Second, we are not comfortable rewarding doctors for withholding a test that could help some men. Screening is a gamble: There may be a few winners who win big (avoid a cancer death), but there are often many more losers (patients who go through false alarms, subsequent testing and unneeded treatment). There is no single formula to solve this equation; individuals in the same situation can look at the same data and legitimately make different decisions. When it comes to medical ethics, patient autonomy is about as fundamental as it gets.
Finally, a performance measure for not screening reinforces a misleading narrative often invoked by screening proponents: Concerns about early detection are really about saving money. That is not true; the issues raised by early detection would be every bit as relevant even if we had all the money in the world.
But early detection is counterintuitive. Most people think that screening works in only one direction: that it can make things only better. But it can also make things worse. Most people think screening will only lower cancer risk. But it can be the fastest way to get a diagnosis of cancer — one that would otherwise never have been noticed, much less caused harm. Most people think that all the “cancer survivors” in the news, and in the neighborhood, provide powerful evidence that screening saves lives. But the survivors whose cancers were caught by screening are less likely to be evidence of its benefit — because many were treated for a cancer that wasn’t going anywhere.
This counterintuitive world of screening was highlighted recently with the apparently alarming news that, with less screening, fewer men are being given a diagnosis of early prostate cancer. It sounds like a bad thing. But it’s exactly what would be expected with less screening — and may turn out to be a benefit.
Nevertheless, screening is a choice. Medicare should not penalize doctors for ordering PSA tests, but it should make sure it is not giving the test away free. Requiring men to bear the small cost of the test is not a punishment, it’s a motivation for them to consider the screening decision more carefully. Not only does the test have important implications for adverse health outcomes in the near future, but it also has near-term implications for some serious out-of-pocket costs from potential follow-up care.
Support the process by rewarding doctors for taking the time to discuss the trade-offs patients face. Medicare already requires, and reimburses for, shared decision making for lung cancer screening; it should do the same for prostate cancer screening.