The death panel libel again

post by Bill Gardner

The US Preventitive Services Task Force has issued a new recommendation about screening for prostate cancer.  Dr. Michael LeFebrvre, The co-chair of the task force, offered this summary:

Prostate cancer is a serious health problem that affects thousands of men and their families. But before getting a PSA test, all men deserve to know what the science tells us about PSA screening: there is a very small potential benefit and significant potential harms. We encourage clinicians to consider this evidence and not screen their patients with a PSA test unless the individual being screened understands what is known about PSA screening and makes the personal decision that even a small possibility of benefit outweighs the known risk of harms.

Cancer screening with the prostate specific antigen (PSA) test has been rigorously studied in hundreds of thousands of patients; the USPSTF recommendation was based on those data.

The Wall St. Journal has published an editorial by Tom Perkins, the founder of Kleiner Perkins and a cancer patient. He summarizes the report as follows:

A recent announcement by the U.S. Preventative Health Service can rather simply be summed up: Most men eventually get prostate cancer, but most don't die from it; those who do are mostly over 75 years of age, so that ends their continuing burden on the public purse. Further, early and prolonged testing is expensive, and can lead to medical complications from biopsy examination.

Mr. Perkins is lying. The recommendation makes no reference to the expense of any medical procedure or any burden on the public purse. The recommendation discusses only the benefits and harms of the use of the PSA test as a screen. Perkins concludes that

A highly taxed and highly regulated economy leads to "Death Panels," like the U.S. Preventative Health Service.

Apparently placing a defamatory claim in quotes makes it ironic or something. You can rationally disagree with the USPSTF. The way to do it is with data.

UPDATE: Go to Carey Goldberg's blog to see a graph that does a terrific job of explaining why current data indicate that the PSA screen provides few benefits and substantial harms. (h/t Austin Frakt)

Comments

[civisisus]

but but but Perkins is rich so he must be correct

[Bill Gardner (@Bill_Gardner)]

civisisus --
You are right. How did I miss that?

[Anonymous]

Neutral observer of the debate here, with an honest question. I understand USPSTF's concerns, but aren't they ignoring the marked decrease in mortality due to prostate cancer (~50%) that has been enjoyed since deploying PSA monitoring? Corellation != causation, but there seems to be no better biomarker for monitoring this surreptitious disease and it's undoubtedly contributed to improved management. Shouldn't they be advocating for smarter screening (start earlier, screen LESS frequently, don't treat low-risk pts), instead of recommending against it altogether? Or maybe maintaining the "I" rating until more data is collected?

I'd love to read a good debate on this topic, as both sides seem to be just sounding-off in their respective corners at this point.

[Bill Gardner (@Bill_Gardner)]

Neutral observer,
Those are excellent suggestions. There is clearly individual variation in risk, and higher risk individuals would be more likely to benefit from treatment. There many ways to do smarter screening.
So why isn't the USPSTF recommending this? I think that it is because there are few data on alternative PSA screening strategies. What we have is data about routine screening at age X. The USPSTF is extremely -- many feel, excessively -- conservative in its recommendations.

[Ravi Singh]

The Göteborg study in Sweden showed that PSA screening is effective when used in the 50 to 64 age group, in comparison to a non-screened control group.
The PLCO trial showed that this benefit is less clear cut when you go up to 74 years, and when you use a control group in which many have been screened at some point.
The USPSTF could have concluded that the Goteborg study was a smarter approach, and recommended PSA screening for men aged 50-64. Instead, they have decided to throw the baby out with the bathwater.

[Bill Gardner (@Bill_Gardner)]

Ravi,
Good suggestion, and as I said, the way to disagree with the USPSTF is with data, not libel.