I Want My Slice of the Pie! Part 3

What if we went along and always followed the rules?  Wouldn't this be a better world?  So goes the thinking but my cynical side tells me that we need to look out for unintended consequences.  As you probably know by now, the USPSTF recently gave prostate cancer screening w/PSA a Grade D recommendation.  The rationale was no evidence of benefit in all-cause mortality.

Sure, maybe you can decrease mortality from one specific cause, but that will only allow an increase in some other cause of death. Think of this as Whac-A-Mole medicine.  Decrease in all-cause mortality is placing a 4x8 sheet of plywood on top of the Whac-A-Mole game such that no moles can pop up, thus we win by maximizing the number of moles whacked.  Yeah, I know, I have a strange way of viewing life.

So anyway, what if we all listened to USPSTF and didn't order any screening PSA tests?  In a study published just last week in Cancer, the authors concluded that not screening w/PSA would triple the number of prostate cancers initially diagnosed at metastatic Stage IV as most recently actually observed in 2008.  Currently, by using PSA screening, we pick up many (most?) cancers as localized Stage I for which another recent study demonstrated no benefit from radical prostatectomy vs observation.

But if we don't pick up early Stage I prostate cancer, when do they present?  As late stage IV metastatic prostate cancer which occurred in 739 men in 2008.  Using annual incidence data from 1983-1985 in the pre-PSA era, the authors multiplied this by the number of men in each corresponding age-race category for 2008.  Their answer?  An estimated 2,277 men would've presented w/metastatic Stage IV cancer in 2008 if they had not used PSA for screening & early detection.

At face value, this study is rather alarmist: after all, who wants to hear about the possibility of tripling the rate of metastatic cancer at diagnosis because we didn't screen earlier?  But guess what?  The authors made no calculation as to all-cause mortality.  Sure, no one wants to be that person who is diagnosed with metastatic cancer but we have limited & finite resources.  How are we to responsibly divvy up said resources?  Especially when there's no impact on all-cause mortality.  Tough decisions have to be made sometime soon because we can't continue to spend freely without any consideration as to economic impact.  PS  Would it surprise you if I noted that 3 of the 4 authors were urologists?  Just sayin'.

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