Sometimes it all depends on your point of view when it comes to areas of divergent opinion about the value of certain medical tests and procedures.
So it should be no surprise that the release earlier this week of the United States Preventive Services Task Force draft statement of their new updated recommendations on the use of the PSA test to screen men for prostate cancer has generated some controversy of its own.
However, this time around it’s not just the advocates or the detractors aiming their fire at the Task Force—it’s journalists and bloggers battling over how media reports and headlines portrayed the impact and ultimate meaning of that draft report (I emphasize “draft” with more on that later). The report basically took the PSA test out of Task Force purgatory by changing the prior recommendation from “don’t do it at all” to a more permissive “have a discussion and make a decision if it’s right for you.”
Here is the nutshell version: In 2012, the Task Force came out with a recommendation that no man at average risk of prostate cancer should have a PSA test in the hope of finding prostate cancer early. They basically said that the test had not been shown to reduce deaths from the disease, and the treatments that would follow such a diagnosis for most men did more harm than good.
At the time, there was a huge outcry from those who were advocates for the benefits of the test, including doctors, researchers and patients along with some disease related advocacy organizations who believed strongly that the test saved lives—even their own lives—and the downsides of the test, such as life-long urinary incontinence, bowel difficulties, and sexual dysfunction were a worthy price to pay to save their lives.
Of course, what wasn’t clearly stated back then was how we got here.
Prostate cancer has been around in men for a long, long time, and historically more often than not did not lead to any particular problem or even death when left undiagnosed and untreated. But with longer life spans (the older a man gets the more likely he is to have prostate cancer develop), and the development of a test to detect the disease early, we began to find more men with prostate cancer and treating them.
The combination of new treatments and a screening tool led to important drops in mortality from prostate cancer. But it also meant we started treating many men who had either nothing wrong with their prostate or some other benign and/or relatively inconsequential disease, as well as men who would have died of something else. The old saying is: prostate cancer is often a disease you die “with”, not “from”.
As time went on, some organizations—including the American Cancer Society—had come to a somewhat different conclusion than the task force had in 2012. While not scorning the PSA test completely as the Task Force had done, several groups said that rather than get the test willy-nilly, men should have the opportunity to have an informational discussion with a health professional, then make a decision that was consistent with their own values: was the potential benefit worth the very real risk of harms from treatment in the absence of a guarantee that treating a prostate cancer more likely than not would not make a difference in their lifespan?
Along the way from 2012 to today in 2017 some interesting things happened:
First, the number of men receiving a PSA test declined. The number of men diagnosed with prostate cancer declined. Perhaps more important and relevant to this discussion is that medicine made a bit of a change when it came to diagnosing and treating prostate cancer by more frequently adopting active surveillance as a viable option for many men diagnosed with low risk prostate cancer.
In the simplest terms, active surveillance means that when a man is diagnosed with prostate cancer, instead of rushing in to cut it with surgery or burn it with radiation, you watch it over time. You see the doctor periodically, have additional blood tests, examinations, imaging studies and biopsies. If the tumor appears to be progressing or changing its character and becoming more aggressive, you treat it. You and your doctor now have information whether your tumor is one that is not going to become a problem, or one that appears to be on the road to bad behavior. Then you can act accordingly to treat it or not, as circumstances dictate.
And here’s the kicker: Medicine actually has moved in a more evidence based direction. Doctors do less surgery and radiation, fewer men have incontinence, and although their sex lives are interrupted, the basis for that interruption may be more understandable. And one still has the opportunity to avoid a death from prostate cancer.
Moving evidence-based medicine forward to improve the care of patients may not be a big deal to some people, but it most certainly is to many of us who have been watching these issues closely. It took many years to understand that a cholesterol of 280 wasn’t healthy (yes, there really was a day when a cholesterol of 280 was normal). It only took us a couple to get the prostate train moving down the right track. In my opinion, that is a very big deal.
So when critics claim the Task Force’s change may not seem like much, I say it really is much. It’s a recognition that the task force is willing to move in a different direction based on the evidence and the beneficial impact of what is happening in the real world—where harms and risks are somewhat mitigated, while whatever benefits that exist are likely to be maintained.
Oh, and about draft (there’s that word again) statements: they are NOT recommendations. They are PRELIMINARY reports available for public examination and comment. Those comments are reviewed, and these preliminary recommendations may be changed when the FINAL report is issued. So, any news story or headline that says “The task force recommends…” is just a bit ahead of the real story and recommendation—which won’t come for months.
There is a lot of legitimate criticism of media coverage particularly premature or unwarranted promotion of new medical tests and technologies. However, the current criticism of articles that have rightly pointed out the significance of the Task Force’s change and what it really implies (assuming you understand the story behind the story) in my humble opinion is simply not justified. Unless—of course—you don’t want to acknowledge that sometimes the medical profession and those we serve actually do the right thing.