Is innumeracy harming the quality of medical care?
June 12, 2012 7:37 PM Subscribe
Since the U.S. Preventive Services Task Force recommended against screening for prostate cancer, the debate has been furious. In fact, screening rates are likely to remain high, because most urologists disagree with the recommendations. One argued, "If you don’t do it, it’s negligent." (The debate is not new. Previously on Metafilter.)
This type of conflict between researchers and practitioners is common. A study of primary care physicians found that a quarter would recommend [PDF] colorectal cancer screening for a terminally ill 80-year old patient.
Why? Fear of lawsuits contributes: 90 percent of physicians "reported believing that physicians order more tests and procedures than needed to protect themselves from malpractice suits."
But another reason might be that many doctors just don't understand the numbers. A recent study asked Do Physicians Understand Cancer Screening Statistics?. Too frequently, the answer is no. In fact, physicians' decisions about whether to order screening tests was more influenced by "irrelevant" than by "relevant" statistics.
This finding is consistent with previous research that too many doctors just aren't very good at the relevant math. As one review [PDF] concluded in 2008, "Unfortunately, for more than 25 years, the skills of physicians in this area have been shown to be poor." For stat geeks who want to feel superior to (and worried about) doctors' statistical knowledge, some gory details are in Table 3 of this article. For example, only 37 percent of residents "could interpret an adjusted odds ratio from a multivariate regression analysis."
This type of conflict between researchers and practitioners is common. A study of primary care physicians found that a quarter would recommend [PDF] colorectal cancer screening for a terminally ill 80-year old patient.
Why? Fear of lawsuits contributes: 90 percent of physicians "reported believing that physicians order more tests and procedures than needed to protect themselves from malpractice suits."
But another reason might be that many doctors just don't understand the numbers. A recent study asked Do Physicians Understand Cancer Screening Statistics?. Too frequently, the answer is no. In fact, physicians' decisions about whether to order screening tests was more influenced by "irrelevant" than by "relevant" statistics.
This finding is consistent with previous research that too many doctors just aren't very good at the relevant math. As one review [PDF] concluded in 2008, "Unfortunately, for more than 25 years, the skills of physicians in this area have been shown to be poor." For stat geeks who want to feel superior to (and worried about) doctors' statistical knowledge, some gory details are in Table 3 of this article. For example, only 37 percent of residents "could interpret an adjusted odds ratio from a multivariate regression analysis."
hippybear: "But casual screening simply because you're getting older is actually sort of pointless once you reach a certain age, especially with this particular cancer."
I'm not sure I understand why. Can you please explain? I know that early detection of most cancers is the key to survival for most cancers, including breast, skin, liver, testicular, esophageal and ovarian. It seems almost counterintuitive to me that prostate cancer would be different.
posted by zarq at 7:49 PM on June 12, 2012
I'm not sure I understand why. Can you please explain? I know that early detection of most cancers is the key to survival for most cancers, including breast, skin, liver, testicular, esophageal and ovarian. It seems almost counterintuitive to me that prostate cancer would be different.
posted by zarq at 7:49 PM on June 12, 2012
This has been interesting. I had a physical about 6 weeks ago. The nurse practitioner gave my prostate a clean bill of health.
Then I had a routine colonoscopy, and the doctor who did that took a side trip to my protate and reported some "nodularity." Asked the nurse practitioner about this and she said that her fingers were too short to get to all of it. Hmmmm.
PSA off the charts low, but having a biopsy in two more weeks. Hoping that it's just a calcium deposit. For me, the PSA was just another data point.
I have been gaming it all out in my head, and think that I could do without this organ, if it came to that, rather than have it kill me eventually.
But, as much as I have tried to get my head around this controversy, I still do not understand the issues, or, really, what the researchers and docs are talking about, really.
posted by Danf at 7:53 PM on June 12, 2012 [1 favorite]
Then I had a routine colonoscopy, and the doctor who did that took a side trip to my protate and reported some "nodularity." Asked the nurse practitioner about this and she said that her fingers were too short to get to all of it. Hmmmm.
PSA off the charts low, but having a biopsy in two more weeks. Hoping that it's just a calcium deposit. For me, the PSA was just another data point.
I have been gaming it all out in my head, and think that I could do without this organ, if it came to that, rather than have it kill me eventually.
But, as much as I have tried to get my head around this controversy, I still do not understand the issues, or, really, what the researchers and docs are talking about, really.
posted by Danf at 7:53 PM on June 12, 2012 [1 favorite]
"More inside."
I'll take "things you DON'T want to hear during prostate screening" for $200, Alex.
posted by ShutterBun at 7:53 PM on June 12, 2012 [8 favorites]
I'll take "things you DON'T want to hear during prostate screening" for $200, Alex.
posted by ShutterBun at 7:53 PM on June 12, 2012 [8 favorites]
Where are all these GPs who order more tests than necessary? Cause I have to fight with mine to get them to run more than a white blood cell count half the time. Had to get my damned rheumatologist to run my kidney levels after a ct showed multiple kidney and bladder stones, cause the GP wouldn't!
posted by strixus at 7:54 PM on June 12, 2012 [2 favorites]
posted by strixus at 7:54 PM on June 12, 2012 [2 favorites]
zarq: because the most common form of prostate cancer is very slow moving, taking decades or more to metastasize and become life threatening. If you're, say, 70 years old and are diagnosed with the typical form of prostate cancer, the chances are that something else will kill you before the cancer does.
I believe that I've read that the best screening process for prostate cancer is once every 10 years above the age of 40 unless symptoms suggest otherwise, and once you hit 60 or 70, not to bother with the screening unless you have a family history which suggests you might have a proclivity toward the faster-moving, much more rare form of prostate cancer.
posted by hippybear at 7:57 PM on June 12, 2012 [3 favorites]
I believe that I've read that the best screening process for prostate cancer is once every 10 years above the age of 40 unless symptoms suggest otherwise, and once you hit 60 or 70, not to bother with the screening unless you have a family history which suggests you might have a proclivity toward the faster-moving, much more rare form of prostate cancer.
posted by hippybear at 7:57 PM on June 12, 2012 [3 favorites]
Nobody wants to be the doctor who doesn't screen the guy who dies. Nobody wants to be the guy who doesn't get screened and dies because of it.
The tests are not dangerous or even that inconvenient. The cancer treatments are. Essentially, the anti-screening argument exists to prevent unnecessary treatment. But you in fact prevent unnecessary treatment by informing patients, not by enforcing ignorance of any aspect of your physical condition.
I, personally, would like as much information as possible to help me make informed decisions regarding my own objectives, which are to cling to life as much as possible. I respect people who use different criteria. I do not respect their wish to make me obey those criteria. If the state wants to dissuade me, it can make me pay for the treatment.
Statistical outliers are human beings. I say this as an outlier. My Dad died from colon cancer. I have a screening coming up--Got 'em every 5 years, for the rest of my life. Dad never got that. He was dying by the time they got a look at that. Somehow, the fact that he was missed by a statistical model is no fucking comfort for me.
posted by mobunited at 7:57 PM on June 12, 2012 [10 favorites]
The tests are not dangerous or even that inconvenient. The cancer treatments are. Essentially, the anti-screening argument exists to prevent unnecessary treatment. But you in fact prevent unnecessary treatment by informing patients, not by enforcing ignorance of any aspect of your physical condition.
I, personally, would like as much information as possible to help me make informed decisions regarding my own objectives, which are to cling to life as much as possible. I respect people who use different criteria. I do not respect their wish to make me obey those criteria. If the state wants to dissuade me, it can make me pay for the treatment.
Statistical outliers are human beings. I say this as an outlier. My Dad died from colon cancer. I have a screening coming up--Got 'em every 5 years, for the rest of my life. Dad never got that. He was dying by the time they got a look at that. Somehow, the fact that he was missed by a statistical model is no fucking comfort for me.
posted by mobunited at 7:57 PM on June 12, 2012 [10 favorites]
A big part of it is that people prefer control over saftey. That's why people often feel safer driving compared to flying. When you're flying, you're very safe, but you have no control over the situation. When you're driving you have complete control over your own car, even if statistics show that you're much more likely to screw up and kill yourself then you are to die in a plane crash.
So an unnecessary operation doesn't just waste money, it also can potentially kill you before the cancer would.
Obviously though, it seems like it would be better to tell people that, and let them make the choice. Sure, they would probably make the wrong choice but again it comes down to control vs. safety. A person might be more likely to live if they're not examined and don't have the opportunity to make the wrong choice. But again, people are willing to give up statistical safety for control over the situation.
posted by delmoi at 7:59 PM on June 12, 2012 [5 favorites]
I know that early detection of most cancers is the key to survival for most cancersYou can die in surgery, especially if you're old. Or you can get an infection -- remember, tens of thousands of people die every year in the US from infections they get in hospitals. (30k in the UK, apparently). Overall, IIRC the death rate from medical malpractice is in the hundreds of thousands.
So an unnecessary operation doesn't just waste money, it also can potentially kill you before the cancer would.
Obviously though, it seems like it would be better to tell people that, and let them make the choice. Sure, they would probably make the wrong choice but again it comes down to control vs. safety. A person might be more likely to live if they're not examined and don't have the opportunity to make the wrong choice. But again, people are willing to give up statistical safety for control over the situation.
posted by delmoi at 7:59 PM on June 12, 2012 [5 favorites]
I know that early detection of most cancers is the key to survival for most cancers, including breast, skin, liver, testicular, esophageal and ovarian.
Early detection does lead to increased survival rates. It does not necessarily lead to reduced mortality rates. There is a important difference, illustrated by Aaron Carroll at The Incidental Economist:
Let’s say there’s a new cancer of the thumb killing people. From the time the first cancer cell appears, you have nine years to live, with chemo. From the time you can feel a lump, you have four years to live, with chemo. Let’s say we have no way to detect the disease until you feel a lump. The five year survival rate for this cancer is about 0, because within five years of detection, everyone dies, even on therapy.
Now I invent a new scanner that can detect thumb cancer when only one cell is there. Because it’s the United States, we invest heavily in those scanners. Early detection is everything, right? We have protests and lawsuits and now everyone is getting scanned like crazy. Not only that, but people are getting chemo earlier and earlier for the cancer. Sure, the side effects are terrible, but we want to live.
We made no improvements to the treatment. Everyone is still dying four years after they feel the lump. But since we are making the diagnosis five years earlier, our five year survival rate is now approaching 100%! Everyone is living nine years with the disease. Meanwhile, in England, they say that the scanner doesn’t extend life and won’t pay for it. Rationing! That’s why their five year survival rate is still 0%.
posted by Snerd at 8:02 PM on June 12, 2012 [23 favorites]
Early detection does lead to increased survival rates. It does not necessarily lead to reduced mortality rates. There is a important difference, illustrated by Aaron Carroll at The Incidental Economist:
Let’s say there’s a new cancer of the thumb killing people. From the time the first cancer cell appears, you have nine years to live, with chemo. From the time you can feel a lump, you have four years to live, with chemo. Let’s say we have no way to detect the disease until you feel a lump. The five year survival rate for this cancer is about 0, because within five years of detection, everyone dies, even on therapy.
Now I invent a new scanner that can detect thumb cancer when only one cell is there. Because it’s the United States, we invest heavily in those scanners. Early detection is everything, right? We have protests and lawsuits and now everyone is getting scanned like crazy. Not only that, but people are getting chemo earlier and earlier for the cancer. Sure, the side effects are terrible, but we want to live.
We made no improvements to the treatment. Everyone is still dying four years after they feel the lump. But since we are making the diagnosis five years earlier, our five year survival rate is now approaching 100%! Everyone is living nine years with the disease. Meanwhile, in England, they say that the scanner doesn’t extend life and won’t pay for it. Rationing! That’s why their five year survival rate is still 0%.
posted by Snerd at 8:02 PM on June 12, 2012 [23 favorites]
I'm not sure I understand why. Can you please explain?
The understanding I get from reading the article linked under the "against screening" link indicates that there is real harm from screening, false positives and the treatment that people might get for very early stage cancer treatment. So let's say you have some sort of super slow growing cancer and you are an older man. Treatment might make you incontintent or give you erectile dysfunction for a slow-growing cancer that would likely not [again, running the numbers which is what the OP is talking about] give you any negative health effects from the cancer in the length of time you likely had available. And it's counterintuitive, which is why a lot of urologists are basically ignoring the math and doing the tests anyhow. It's a really weird and interesting health problem.
So, for a real life example, my mom has DCIS which is a slow growing breast cancer. She gets regular checkups to get it looked at to make sure it is, in fact, slow growing. A few years ago she got a grim lung cancer diagnosis and basically they stopped checking the DCIS because there was no way it would grow quickly enough to kill her, not faster than the lung cancer in any rate. She has been doing well on the medication she is taking and the lung cancer is in a weird not-progressing state, so much so that she's had to start getting the DCIS inspected again because it might be problematic now that her prognosis has improved. Which is ... good news? But basically the docs are concerned with what is the real threat to your health and in the case of prostate exams, the exam itself has more likely negative outcomes than early detection and treatment. Or, what Snerd and hippybear have said, above.
posted by jessamyn at 8:03 PM on June 12, 2012 [3 favorites]
The understanding I get from reading the article linked under the "against screening" link indicates that there is real harm from screening, false positives and the treatment that people might get for very early stage cancer treatment. So let's say you have some sort of super slow growing cancer and you are an older man. Treatment might make you incontintent or give you erectile dysfunction for a slow-growing cancer that would likely not [again, running the numbers which is what the OP is talking about] give you any negative health effects from the cancer in the length of time you likely had available. And it's counterintuitive, which is why a lot of urologists are basically ignoring the math and doing the tests anyhow. It's a really weird and interesting health problem.
So, for a real life example, my mom has DCIS which is a slow growing breast cancer. She gets regular checkups to get it looked at to make sure it is, in fact, slow growing. A few years ago she got a grim lung cancer diagnosis and basically they stopped checking the DCIS because there was no way it would grow quickly enough to kill her, not faster than the lung cancer in any rate. She has been doing well on the medication she is taking and the lung cancer is in a weird not-progressing state, so much so that she's had to start getting the DCIS inspected again because it might be problematic now that her prognosis has improved. Which is ... good news? But basically the docs are concerned with what is the real threat to your health and in the case of prostate exams, the exam itself has more likely negative outcomes than early detection and treatment. Or, what Snerd and hippybear have said, above.
posted by jessamyn at 8:03 PM on June 12, 2012 [3 favorites]
I just want to note that the screening itself is often more than an "inconvenience". From the the above site:
"Over 10 years, approximately 15% to 20% of men will have a PSA test result that triggers a biopsy, depending on the PSA threshold and testing interval used (4). New evidence from a randomized trial of treatment of screen-detected cancer indicates that roughly one third of men who have prostate biopsy experience pain, fever, bleeding, infection, transient urinary difficulties, or other issues requiring clinician follow-up that the men consider a “moderate or major problem”; approximately 1% require hospitalization (6)."
I also know that for at least some folks just the initial screening is a debilitating experience that takes days and days of sheer unpleasantness.
posted by contrarian at 8:08 PM on June 12, 2012 [1 favorite]
"Over 10 years, approximately 15% to 20% of men will have a PSA test result that triggers a biopsy, depending on the PSA threshold and testing interval used (4). New evidence from a randomized trial of treatment of screen-detected cancer indicates that roughly one third of men who have prostate biopsy experience pain, fever, bleeding, infection, transient urinary difficulties, or other issues requiring clinician follow-up that the men consider a “moderate or major problem”; approximately 1% require hospitalization (6)."
I also know that for at least some folks just the initial screening is a debilitating experience that takes days and days of sheer unpleasantness.
posted by contrarian at 8:08 PM on June 12, 2012 [1 favorite]
I also know that for at least some folks just the initial screening is a debilitating experience that takes days and days of sheer unpleasantness.
Having someone's lubed, gloved finger up your butt for two or three seconds?
Are you saying that there is some sort of trauma to the prostate that takes a few days to get over? Could be true, I guess, but I have not heard this.
posted by Danf at 8:19 PM on June 12, 2012
Having someone's lubed, gloved finger up your butt for two or three seconds?
Are you saying that there is some sort of trauma to the prostate that takes a few days to get over? Could be true, I guess, but I have not heard this.
posted by Danf at 8:19 PM on June 12, 2012
jessamyn, hippybear, thank you. That makes sense. And yes, it's very weird situation.
A number of my friends have died within the last two years, after suffering from several different kinds of cancer. They all were diagnosed late -- only after they had reached stages three and four, so they had difficult, uphill battles. As a result, ignoring cancer screening tests goes against all my instincts. It's hard to conceive that the screening could possibly be worse than living with the disease.
Snerd, thanks for the link to the preventing overdiagnosis article. Absolutely true that screening in many cases doesn't necessarily do anything other than put off the inevitable. But having known folks who would have given anything for the extra time early screening could have given them, it's hard to believe they wouldn't have thought it worth any costs, risks or complications.
posted by zarq at 8:20 PM on June 12, 2012
A number of my friends have died within the last two years, after suffering from several different kinds of cancer. They all were diagnosed late -- only after they had reached stages three and four, so they had difficult, uphill battles. As a result, ignoring cancer screening tests goes against all my instincts. It's hard to conceive that the screening could possibly be worse than living with the disease.
Snerd, thanks for the link to the preventing overdiagnosis article. Absolutely true that screening in many cases doesn't necessarily do anything other than put off the inevitable. But having known folks who would have given anything for the extra time early screening could have given them, it's hard to believe they wouldn't have thought it worth any costs, risks or complications.
posted by zarq at 8:20 PM on June 12, 2012
If a screening indicates you need a biopsy, then your doctor should tell you about the pros and cons of the biopsy.
As for the initial screening. Yes, in a medical context things up your bum involve unpleasantness. These issues should weigh into making an informed decision. There's a minute chance my upcoming colonoscopy will kill me. The people who do it told me. They let me decide.
posted by mobunited at 8:22 PM on June 12, 2012 [2 favorites]
As for the initial screening. Yes, in a medical context things up your bum involve unpleasantness. These issues should weigh into making an informed decision. There's a minute chance my upcoming colonoscopy will kill me. The people who do it told me. They let me decide.
posted by mobunited at 8:22 PM on June 12, 2012 [2 favorites]
I also know that for at least some folks just the initial screening is a debilitating experience that takes days and days of sheer unpleasantness.
Having someone's lubed, gloved finger up your butt for two or three seconds?
No. If you read the comment you quoted from carefully, you will see this refers specifically to a PSA screening which then triggers a biopsy, which is the procedure which can cause all these horrible side effects.
The side effects are not from a digital exam. They are from having 6-12 hollow needles shot into both halves of your prostate in order to take tissue samples.
posted by hippybear at 8:25 PM on June 12, 2012 [1 favorite]
Having someone's lubed, gloved finger up your butt for two or three seconds?
No. If you read the comment you quoted from carefully, you will see this refers specifically to a PSA screening which then triggers a biopsy, which is the procedure which can cause all these horrible side effects.
The side effects are not from a digital exam. They are from having 6-12 hollow needles shot into both halves of your prostate in order to take tissue samples.
posted by hippybear at 8:25 PM on June 12, 2012 [1 favorite]
Nobody wants to be the doctor who doesn't screen the guy who dies. Nobody wants to be the guy who doesn't get screened and dies because of it.
But you in fact prevent unnecessary treatment by informing patients, not by enforcing ignorance of any aspect of your physical condition.
The issue is that these two things are contradictory. Say you support screening like crazy and everyone's getting screened all the time. Then you just shifted the screening catch-22 onto treatment. You're going to have a hell of a time persuading people they don't want/need treatment (because they'll die anyway and it'll just make them feel like crap or because they'll die of old age before the cancer kills them), just like trying to explain to people they probably don't need screening that often.
posted by hoyland at 8:30 PM on June 12, 2012 [1 favorite]
But you in fact prevent unnecessary treatment by informing patients, not by enforcing ignorance of any aspect of your physical condition.
The issue is that these two things are contradictory. Say you support screening like crazy and everyone's getting screened all the time. Then you just shifted the screening catch-22 onto treatment. You're going to have a hell of a time persuading people they don't want/need treatment (because they'll die anyway and it'll just make them feel like crap or because they'll die of old age before the cancer kills them), just like trying to explain to people they probably don't need screening that often.
posted by hoyland at 8:30 PM on June 12, 2012 [1 favorite]
The side effects are not from a digital exam. They are from having 6-12 hollow needles shot into both halves of your prostate in order to take tissue samples.
Which is happening for me in two weeks. But I recently had a melanoma scare, and in the off chance that this bump is an aggressive cancer, rather than a slow moving one or a calcium deposit, I would like to know sooner than later. I am a very young 61 and plan on being around for awhile more, if possible. The thought of not being able to get it up anymore scares me, but if the worst happens, at least I'll be around to please my wife in other ways.
Now if I were 70 and more infirm than I am now, it might be a different story.
posted by Danf at 8:39 PM on June 12, 2012 [2 favorites]
Which is happening for me in two weeks. But I recently had a melanoma scare, and in the off chance that this bump is an aggressive cancer, rather than a slow moving one or a calcium deposit, I would like to know sooner than later. I am a very young 61 and plan on being around for awhile more, if possible. The thought of not being able to get it up anymore scares me, but if the worst happens, at least I'll be around to please my wife in other ways.
Now if I were 70 and more infirm than I am now, it might be a different story.
posted by Danf at 8:39 PM on June 12, 2012 [2 favorites]
" They are from having 6-12 hollow needles shot into both halves of your prostate in order to take tissue samples."
I do not have a prostate. Buy if I did have a prostate, it would now have retracted itself up to the general vicinity of my lungs.
posted by Eyebrows McGee at 9:05 PM on June 12, 2012 [3 favorites]
I do not have a prostate. Buy if I did have a prostate, it would now have retracted itself up to the general vicinity of my lungs.
posted by Eyebrows McGee at 9:05 PM on June 12, 2012 [3 favorites]
zarq writes "Snerd, thanks for the link to the preventing overdiagnosis article. Absolutely true that screening in many cases doesn't necessarily do anything other than put off the inevitable. But having known folks who would have given anything for the extra time early screening could have given them, it's hard to believe they wouldn't have thought it worth any costs, risks or complications."
In Snerd's example it doesn't actually "put off the inevitable"; the early detection just makes you aware of the inevitable much earlier. IE: you still die on the same day, give or take, you are just aware you are dieing earlier. And me, if I'm going to die 10 years from now I'd rather know that 5 years from now rather than 5 days from now. I know not everyone feels that way.
posted by Mitheral at 9:07 PM on June 12, 2012
In Snerd's example it doesn't actually "put off the inevitable"; the early detection just makes you aware of the inevitable much earlier. IE: you still die on the same day, give or take, you are just aware you are dieing earlier. And me, if I'm going to die 10 years from now I'd rather know that 5 years from now rather than 5 days from now. I know not everyone feels that way.
posted by Mitheral at 9:07 PM on June 12, 2012
Danf, I just had prostate biopsy three weeks ago. My PSA had doubled in a year but was still in the normal range. My primary care physician said I could have another PSA test in 6 months and see what it is then or go see a Urologist. I chose to see the Urologist. He said that with the symptoms I presented and the rapid change in PSA, along with my age (51) that he recommended an ultrasound and biopsy. Warning, it gets graphic after this. The biopsy is uncomfortable but not too painful, about the level of dental work. You are prescribed an antibiotic to take two hours before the procedure. The doctor uses a local anesthetic. He inserts an anal ultrasound probe to look at your prostate. Mine was double normal size. You will see the 12 sample bottles that your tissue will go into. You can feel the needle go deep into you when he takes the samples. The whole procedure is less than 15 minutes. The tough part is when you're done and the anesthetic wears off. You will have a very painful afternoon. You will pee blood for the rest of that day but will feel much better the second day. You may have blood in your stool. You will have blood in your ejaculate for about the next dozen ejaculations. My biopsies came back negative but I do have a chronic infection that's being treated with cipro. I go back in a couple of weeks to see if the PSA level is down.
posted by Grumpy old geek at 9:09 PM on June 12, 2012 [5 favorites]
posted by Grumpy old geek at 9:09 PM on June 12, 2012 [5 favorites]
Screening the average american makes little sense. Screening an extremely healthy person over fifty who will likely see 90+ years of decent health with continued attention to diet and exercise does.
Part of what makes these studies frustrating is knowing how many billions we throw down a rathole every year on self inflicted illness while debates from cost-benefit analysis think-tanks like this over basic screening continue to get so much press.
posted by docpops at 9:24 PM on June 12, 2012 [1 favorite]
Part of what makes these studies frustrating is knowing how many billions we throw down a rathole every year on self inflicted illness while debates from cost-benefit analysis think-tanks like this over basic screening continue to get so much press.
posted by docpops at 9:24 PM on June 12, 2012 [1 favorite]
Also, Tommy Chong thinks his stint in prison gave him the cancer, apparently because he was off his pot. So his treatment, naturally, will be pot.
posted by docpops at 9:26 PM on June 12, 2012 [1 favorite]
posted by docpops at 9:26 PM on June 12, 2012 [1 favorite]
Maybe it's just the outrageous cynic in me, but I've been more than halfway convinced that the recent position change of 'no no, DON'T get screened for cancer now!' is being backed by the insurance companies who a) don't want to have to pay for the screenings and b) want as much time to go by as possible before it's discovered and they may have to pay out for treatments.
posted by FatherDagon at 10:20 PM on June 12, 2012 [2 favorites]
posted by FatherDagon at 10:20 PM on June 12, 2012 [2 favorites]
Which really speaks to the sad state our medical/payment system is in right now...
posted by Windopaene at 10:53 PM on June 12, 2012
posted by Windopaene at 10:53 PM on June 12, 2012
This debate just breaks my heart, almost every day. Urologists literally have a huge financial interest screening because it results in lots and lots of referrals for biopsies from primary care doctors. Sure, they are also concerned about their patients, but you cannot ignore the financial impact of this policy has on their pocket book when they argue against recommendations made by a very well respected independent a group that has *no* agenda or affiliation to anything other that the science. At this point, there have been hundreds of studies on literally hundreds of thousands of men and if there is no clear answer to this question, I am focusing my energy on other things, implementing the preventive services we *know* have measurable benefit yet are implemented far less often than ought to be acceptable. Lipid screening, smoking cessation, weight loss, colon cancer screening, breast cancer screening, mammograms -- there is no question that there are measurable benefits with specific interventions in these areas, yet we are actually delivering these services appallingly infrequently, why am I going to spend 15 minutes discussing pros and cons of prostate cancer screening with a 50 year old man, when I could spend 2 minutes discussing smoking and have a 10% chance of getting him to quit, another 2 minutes discussing colon cancer screening which results in a 50% chance that he'll get a colonscopy and decrease his risk of colon cancer death by more than half, spend 5 minutes discussing cholesterol measurement and counseling on the results and still have 6 minutes left over to ask about his family or his golf game.
The problem with prostate cancer isn't just the false positives and discomfort and complications of the screening program, it's also that right now doctors just aren't all that great at *treating prostate cancer* and we aren't much better at treating it in it's early stages, and despite what urologists and oncologists tell you, the epidemiologic truth of this statement hasn't changed much over time and by now the numbers are great enough in the studies that they aren't likely to change much given the current state of things.
Efficacy of screening test in prolonging life = Prevalence of disease in population X Accuracy of screening test x morbidity of screening test (-false positives and -harm from testing) + effectiveness of treatment*how much more effective treatment is if disease found early before symptoms. I am paraphrasing this equation so it makes conceptual sense.
Prevalence of disease, prostate cancer: high
Accuracy of test, PSA followed by biopsy: moderately high
morbidity of test, biopsy: moderately low
Effectiveness of treatment, prostate cancer: moderate
Improvement of treatment, prostate cancer detected earlier by screening: low
All of this multiplies out to a test that, if applied to 1000 asymptomatic men, few, if any, will end up prolonging their life if they go through this. And the people who are arguing for doing the test, are people with anecdotes about someone who had prostate cancer and the doctor saved them, and the people with a financial incentive in performing the test.
I remember a couple years ago, Steve Forbes came down with prostate cancer and used the news that the USPSTF recommend against routine PSA testing to rail about OBAMACARE DEATH PANELS! In reality, Forbes was diagnosed based on a physical exam finding his doctor discovered (ie he wasn't going through primary preventive "screening"), it is yet to be determined (and really, it is impossible determine on an individual basis) whether his treatment is going to improve the longevity and quality of his life. And finally, though the writers of legislation and policies cite the USPSTF as a source, the USPSTF has gone out of their way to make very public and very clear, that they are a *scientific* organization, that evaluates the quality of the *science* done and published on their research questions and they are very reluctant to bring in the spectre of bias if they are seen as the people who approve or disapprove of specific medical tests. Health policy analysts wisely look to the USPSTF reports and recommendations because that is literally where the best science is right now.
I am perfectly willing to concede that this may all change if there is a substantial change in screening test technology, or in treatment, but at the current standard of care, I feel this is an answered question at this point and just reworking old data or getting more numbers or longer follow up isn't going to change things, the current data quality is high, the numbers are high, and the legnth of follow up is adequate.
Because insurance still pays for this, if I am seeing a patient who really wants it, and wants to spend their 15 minutes with me discussing all of these issues, I will do it, but really that has left no time for us to talk about that nasty looking mole on their back, or their excess alcohol use, or why haven't they received a pertussis booster when we are having a big local outbreak and they have a small child at home, and I have improved their health in no way, and at a cost of perhaps $250 to their insurance company.
It's important to realize that the PSA, rectal exam, biopsy are all still really great diagnostic tools when you have some evidence of existing disease that needs work up, and clearly there are interventions that *can* be effective if prostate cancer is known to be present, but we're talking about testing and treating men who have no symptoms or diagnosis whatsoever.
posted by Slarty Bartfast at 11:12 PM on June 12, 2012 [17 favorites]
The problem with prostate cancer isn't just the false positives and discomfort and complications of the screening program, it's also that right now doctors just aren't all that great at *treating prostate cancer* and we aren't much better at treating it in it's early stages, and despite what urologists and oncologists tell you, the epidemiologic truth of this statement hasn't changed much over time and by now the numbers are great enough in the studies that they aren't likely to change much given the current state of things.
Efficacy of screening test in prolonging life = Prevalence of disease in population X Accuracy of screening test x morbidity of screening test (-false positives and -harm from testing) + effectiveness of treatment*how much more effective treatment is if disease found early before symptoms. I am paraphrasing this equation so it makes conceptual sense.
Prevalence of disease, prostate cancer: high
Accuracy of test, PSA followed by biopsy: moderately high
morbidity of test, biopsy: moderately low
Effectiveness of treatment, prostate cancer: moderate
Improvement of treatment, prostate cancer detected earlier by screening: low
All of this multiplies out to a test that, if applied to 1000 asymptomatic men, few, if any, will end up prolonging their life if they go through this. And the people who are arguing for doing the test, are people with anecdotes about someone who had prostate cancer and the doctor saved them, and the people with a financial incentive in performing the test.
I remember a couple years ago, Steve Forbes came down with prostate cancer and used the news that the USPSTF recommend against routine PSA testing to rail about OBAMACARE DEATH PANELS! In reality, Forbes was diagnosed based on a physical exam finding his doctor discovered (ie he wasn't going through primary preventive "screening"), it is yet to be determined (and really, it is impossible determine on an individual basis) whether his treatment is going to improve the longevity and quality of his life. And finally, though the writers of legislation and policies cite the USPSTF as a source, the USPSTF has gone out of their way to make very public and very clear, that they are a *scientific* organization, that evaluates the quality of the *science* done and published on their research questions and they are very reluctant to bring in the spectre of bias if they are seen as the people who approve or disapprove of specific medical tests. Health policy analysts wisely look to the USPSTF reports and recommendations because that is literally where the best science is right now.
I am perfectly willing to concede that this may all change if there is a substantial change in screening test technology, or in treatment, but at the current standard of care, I feel this is an answered question at this point and just reworking old data or getting more numbers or longer follow up isn't going to change things, the current data quality is high, the numbers are high, and the legnth of follow up is adequate.
Because insurance still pays for this, if I am seeing a patient who really wants it, and wants to spend their 15 minutes with me discussing all of these issues, I will do it, but really that has left no time for us to talk about that nasty looking mole on their back, or their excess alcohol use, or why haven't they received a pertussis booster when we are having a big local outbreak and they have a small child at home, and I have improved their health in no way, and at a cost of perhaps $250 to their insurance company.
It's important to realize that the PSA, rectal exam, biopsy are all still really great diagnostic tools when you have some evidence of existing disease that needs work up, and clearly there are interventions that *can* be effective if prostate cancer is known to be present, but we're talking about testing and treating men who have no symptoms or diagnosis whatsoever.
posted by Slarty Bartfast at 11:12 PM on June 12, 2012 [17 favorites]
The tests are not dangerous or even that inconvenient.
Aside from the whole finger(s) in the ass thing.
posted by LordSludge at 11:21 PM on June 12, 2012
Aside from the whole finger(s) in the ass thing.
posted by LordSludge at 11:21 PM on June 12, 2012
Prevalence of disease, prostate cancer: high
What exactly constitutes "high" as prevalence here? The stats on these pages suggest that 1) it is usually diagnosed late in life and is not the primary cause of death, and 2) that across the full lifespan of males, only 154 out of 100K men will be diganosed with prostate cancer in a given year. Also contained in those statistics is that fewer than 2% of men alive today have been diagnosed with prostate cancer. (~2.5 million in 2009)
So... is 1% of a population with a disease actually "high" in prevalence?
I'm asking this in all seriousness. Because 2% of the total male population with a condition, most of them diagnosed after the age of 60, doesn't sound like really that high of a prevalence to me.
posted by hippybear at 11:27 PM on June 12, 2012
What exactly constitutes "high" as prevalence here? The stats on these pages suggest that 1) it is usually diagnosed late in life and is not the primary cause of death, and 2) that across the full lifespan of males, only 154 out of 100K men will be diganosed with prostate cancer in a given year. Also contained in those statistics is that fewer than 2% of men alive today have been diagnosed with prostate cancer. (~2.5 million in 2009)
So... is 1% of a population with a disease actually "high" in prevalence?
I'm asking this in all seriousness. Because 2% of the total male population with a condition, most of them diagnosed after the age of 60, doesn't sound like really that high of a prevalence to me.
posted by hippybear at 11:27 PM on June 12, 2012
This screening, the continued demand for this screening and what happens if doctors don't recommend it is discussed in Act 2 of this TAL episode on healthcare: More is Less
posted by bobobox at 4:01 AM on June 13, 2012 [1 favorite]
posted by bobobox at 4:01 AM on June 13, 2012 [1 favorite]
I do not have a prostate. Buy if I did have a prostate, it would now have retracted itself up to the general vicinity of my lungs.
If that were anatomically possible, 'brows, that is where mine would be. I don't know how we walk around with these things.
posted by Danf at 5:21 AM on June 13, 2012 [1 favorite]
The Doctor Who Invented PSA Test Calls It “A Profit-Driven Public Health Disaster”
“the test is hardly more effective than a coin toss. As I’ve been trying to make clear for many years now, P.S.A. testing can’t detect prostate cancer and, more important, it can’t distinguish between the two types of prostate cancer — the one that will kill you and the one that won’t. “
“Prostate-specific antigen testing does have a place. After treatment for prostate cancer, for instance, a rapidly rising score indicates a return of the disease. And men with a family history of prostate cancer should probably get tested regularly. If their score starts skyrocketing, it could mean cancer. But these uses are limited. Testing should absolutely not be deployed to screen the entire population of men over the age of 50, the outcome pushed by those who stand to profit.”
Misaligned incentives like these add to the issue of innumeracy in the misdirection of medical resources. Attempts to address the problem by providing an ostensibly objective reference for standards of care, such as NICE in the UK, are still subject to political pressure from ministers, and therefore indirectly from patients' groups and of course from those who stand to profit. Regrettably, the vector sum of all of these forces is typically a push in the direction of earlier and more aggressive intervention than is warranted, which results in sub-optimal patient outcomes and inefficient spending, all because no-one wants to be the person who recommended no treatment.
posted by Jakey at 5:54 AM on June 13, 2012 [2 favorites]
“the test is hardly more effective than a coin toss. As I’ve been trying to make clear for many years now, P.S.A. testing can’t detect prostate cancer and, more important, it can’t distinguish between the two types of prostate cancer — the one that will kill you and the one that won’t. “
“Prostate-specific antigen testing does have a place. After treatment for prostate cancer, for instance, a rapidly rising score indicates a return of the disease. And men with a family history of prostate cancer should probably get tested regularly. If their score starts skyrocketing, it could mean cancer. But these uses are limited. Testing should absolutely not be deployed to screen the entire population of men over the age of 50, the outcome pushed by those who stand to profit.”
Misaligned incentives like these add to the issue of innumeracy in the misdirection of medical resources. Attempts to address the problem by providing an ostensibly objective reference for standards of care, such as NICE in the UK, are still subject to political pressure from ministers, and therefore indirectly from patients' groups and of course from those who stand to profit. Regrettably, the vector sum of all of these forces is typically a push in the direction of earlier and more aggressive intervention than is warranted, which results in sub-optimal patient outcomes and inefficient spending, all because no-one wants to be the person who recommended no treatment.
posted by Jakey at 5:54 AM on June 13, 2012 [2 favorites]
As a side note, is it just me or is "digital exam" the most misleading medical term ever?
I hear it and think, "Great, the doc will hold some fancy scanner near my butt. I probably won't even have to take my pants off! This won't be bad at all."
Then I learn that is just means that someone is going to stick a finger up my butt (which I hate).
posted by VTX at 6:17 AM on June 13, 2012
I hear it and think, "Great, the doc will hold some fancy scanner near my butt. I probably won't even have to take my pants off! This won't be bad at all."
Then I learn that is just means that someone is going to stick a finger up my butt (which I hate).
posted by VTX at 6:17 AM on June 13, 2012
Interesting topic that needs much more public discussion. Previous posts about healthcare screening here and here. Dr. Otis Brawley has a good bit on excessive testing in his excellent book How We Do Harm, which I learned of from this post. In it he relates the thumb cancer example snerd mentioned above, and he also gives a real-life example of PSA screening harming one of his patients. This man got a PSA test which was slightly elevated, followed by a biopsy showing a slow growing cancer. Given his age careful watching would have been appropriate,as would not doing the screening in the first place. But it is pretty easy to convince a patient with cancer that they need aggressive treatment and he opted for radical prostatectomy followed by radiation. He ended up impotent and incontinent from the surgery and developed an enterovesical fistula from the radiation. Not only did his quality of life suffer greatly, but he developed a chronic urinary tract infection that eventually led to a fatal bout of sepsis. He didn't die from cancer, though.
On the other end of the spectrum, someone I work with had a physical a while back and was offered a PSA test. He refused for the sorts of reasons mentioned in this thread. When he got to the lab the test was still ordered on his paperwork, so he crossed it off the order for himself. Afterward, the ordering physician went back and reordered the test despite his objections. Needless to say he was not happy. This pissed off patient, who had a test forced on him over his objection was likely better informed on the subject than all of us here. He is a board-certified urologist!
So I have to say that the way we administer screening tests can be pretty screwed up and devotedly needs to be looked at in a cold, rational way. Cancer is scary, but the potential for harm from inappropriate tests is real, too.
posted by TedW at 7:33 AM on June 13, 2012 [1 favorite]
On the other end of the spectrum, someone I work with had a physical a while back and was offered a PSA test. He refused for the sorts of reasons mentioned in this thread. When he got to the lab the test was still ordered on his paperwork, so he crossed it off the order for himself. Afterward, the ordering physician went back and reordered the test despite his objections. Needless to say he was not happy. This pissed off patient, who had a test forced on him over his objection was likely better informed on the subject than all of us here. He is a board-certified urologist!
So I have to say that the way we administer screening tests can be pretty screwed up and devotedly needs to be looked at in a cold, rational way. Cancer is scary, but the potential for harm from inappropriate tests is real, too.
posted by TedW at 7:33 AM on June 13, 2012 [1 favorite]
The rule of thumb that I have been taught about benign prostatic enlargement (which I guess is the same as the slow growing type mentioned above) is that: at age n, n% of men will have it. This has the corollary that most men will die with it, but none will die of it. Of course this has no relevance to prostatic cancer.
However, I have also read in textbooks about the "obvious" differences between prostatic cancer and benign prostatic enlargement (direction of growth, location of neoplasm within the prostate, character of the growth). Are these differences actually non-diagnostic, or are they simply false?
posted by fizban at 7:45 AM on June 13, 2012
However, I have also read in textbooks about the "obvious" differences between prostatic cancer and benign prostatic enlargement (direction of growth, location of neoplasm within the prostate, character of the growth). Are these differences actually non-diagnostic, or are they simply false?
posted by fizban at 7:45 AM on June 13, 2012
Prevalence of disease, prostate cancer: high
Accuracy of test, PSA followed by biopsy: moderately high
morbidity of test, biopsy: moderately low
Effectiveness of treatment, prostate cancer: moderate
Improvement of treatment, prostate cancer detected earlier by screening: low
One very important item is missing from this list.
morbidity of treatment: very high
The number of men maimed by unnecessary treatment for prostate cancer is staggering. It can lead to impotence, incontinence, and chronic pain and bleeding. Although some surgeons are better than others, rates are still very high. And neither radiotherapy nor hormone treatments are any better.
Even the authors of the paper that found a reduction in mortality say
posted by Mental Wimp at 8:58 AM on June 13, 2012 [3 favorites]
Accuracy of test, PSA followed by biopsy: moderately high
morbidity of test, biopsy: moderately low
Effectiveness of treatment, prostate cancer: moderate
Improvement of treatment, prostate cancer detected earlier by screening: low
One very important item is missing from this list.
morbidity of treatment: very high
The number of men maimed by unnecessary treatment for prostate cancer is staggering. It can lead to impotence, incontinence, and chronic pain and bleeding. Although some surgeons are better than others, rates are still very high. And neither radiotherapy nor hormone treatments are any better.
Even the authors of the paper that found a reduction in mortality say
To prevent one prostate-cancer death, 1410 men (or 1068 men who actually underwent screening) would have to be screened, and an additional 48 men would have to be treated.These men receive zero benefit for their costs. This is not to say that mass screening for prostate cancer can't be made effective. If indolent cancers could be identified prior to biopsy and treatment limited to those who truly benefit, it might be a good thing to do. Meanwhile, the USPSTF is not saying no one should be screened, only that a blanket recommendation for all men of a certain age to be screened is not a beneficial policy.
posted by Mental Wimp at 8:58 AM on June 13, 2012 [3 favorites]
No, benign prostate hyperplasia isn't cancer at all; it's benign. The prostate enlarges gradually on its own; if it gets big enough to cause symptoms (usually having to do with urination), it gets called benign prostate hyperplasia or benign prostate hypertrophy.
Prostate cancer is different and involves cancerous cells growing in the prostate. You can have prostate cancer (either the common, slow-moving kind or the rarer, more dangerous kind) without necessarily having an enlarged prostate.
posted by infinitywaltz at 9:00 AM on June 13, 2012 [2 favorites]
Prostate cancer is different and involves cancerous cells growing in the prostate. You can have prostate cancer (either the common, slow-moving kind or the rarer, more dangerous kind) without necessarily having an enlarged prostate.
posted by infinitywaltz at 9:00 AM on June 13, 2012 [2 favorites]
When he got to the lab the test was still ordered on his paperwork, so he crossed it off the order for himself. Afterward, the ordering physician went back and reordered the test despite his objections. Needless to say he was not happy. This pissed off patient, who had a test forced on him over his objection was likely better informed on the subject than all of us here. He is a board-certified urologist!
I had exactly the same experience. Twice. This is a gross violation of medical ethics. That someone would insist on a screening test which had never been shown by rigorous scientific data to be effective astounds me and supports the thesis of the FPP: that physicians are poorly selected and trained to understand biomedical science or public health.
posted by Mental Wimp at 9:06 AM on June 13, 2012 [2 favorites]
I had exactly the same experience. Twice. This is a gross violation of medical ethics. That someone would insist on a screening test which had never been shown by rigorous scientific data to be effective astounds me and supports the thesis of the FPP: that physicians are poorly selected and trained to understand biomedical science or public health.
posted by Mental Wimp at 9:06 AM on June 13, 2012 [2 favorites]
because the most common form of prostate cancer is very slow moving, taking decades or more to metastasize and become life threatening. If you're, say, 70 years old and are diagnosed with the typical form of prostate cancer, the chances are that something else will kill you before the cancer does.
The number of men maimed by unnecessary treatment for prostate cancer is staggering.
Yes. Supportive anecdote: my step-father is a careful guy who does what his doctor says, so he gets all the normal tests and screenings. In his late sixties, he was diagnosed with early-stage prostate cancer, and went on to have the surgery. Today as a result, at the age of 80, he has been impotent and incontinent for the past 12 years. Every time he leaves the house, he is carrying a knapsack of adult diapers and other supplies that he needs to manage his condition. He went through a lot of pain and anxiety during the treatment, and now, as a fastidious guy who prides himself on being fit and energetic for his age, his quality of life is compromised in ways that he finds mortifying. (Like, I remember some fairly uncomfortable dinner-table conversations about treatments for surgery-induced impotence.)
He says if he could do it all over again, he'd skip getting tested, because he believes the cure is worse than the disease. He would rather have died a little earlier, he says, than gone through all this. He is mad that people let him make a lot of choices without clearly explaining the real pros and cons.
posted by Susan PG at 9:26 AM on June 13, 2012 [3 favorites]
The number of men maimed by unnecessary treatment for prostate cancer is staggering.
Yes. Supportive anecdote: my step-father is a careful guy who does what his doctor says, so he gets all the normal tests and screenings. In his late sixties, he was diagnosed with early-stage prostate cancer, and went on to have the surgery. Today as a result, at the age of 80, he has been impotent and incontinent for the past 12 years. Every time he leaves the house, he is carrying a knapsack of adult diapers and other supplies that he needs to manage his condition. He went through a lot of pain and anxiety during the treatment, and now, as a fastidious guy who prides himself on being fit and energetic for his age, his quality of life is compromised in ways that he finds mortifying. (Like, I remember some fairly uncomfortable dinner-table conversations about treatments for surgery-induced impotence.)
He says if he could do it all over again, he'd skip getting tested, because he believes the cure is worse than the disease. He would rather have died a little earlier, he says, than gone through all this. He is mad that people let him make a lot of choices without clearly explaining the real pros and cons.
posted by Susan PG at 9:26 AM on June 13, 2012 [3 favorites]
Another anecdote: My grandfather was diagnosed with prostate cancer a few years back. He's currently 86.
On advice from his physicians and my mother, who's an RN, it's being left untreated.
From the way they spoke, I gathered that wasn't unusual at all.
posted by rewil at 10:09 AM on June 13, 2012 [2 favorites]
On advice from his physicians and my mother, who's an RN, it's being left untreated.
From the way they spoke, I gathered that wasn't unusual at all.
posted by rewil at 10:09 AM on June 13, 2012 [2 favorites]
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Not to say that tests shouldn't be done if there are indications that they are needed. But casual screening simply because you're getting older is actually sort of pointless once you reach a certain age, especially with this particular cancer.
posted by hippybear at 7:44 PM on June 12, 2012 [1 favorite]