Thursday, August 26, 2010

What Drug Companies Promote PSA Testing?

I've been very concerned for many years about the overuse of PSA screening for men, so I'm surprised that I was not aware of this op-ed in the New York Times back on March 10:

Richard Ablin, research professor of immunology and pathology at the University of Arizona, hammered away at what he calls the "great prostate mistake," routine screening for prostate cancer that costs $3B annually in the US and that ends up leaving 47 men "who can no longer function sexually or stay out of the bathroom for long" for each 1 man who might (under the most optimistic study yet published) have been saved from death by having had the test. (Another equally good study says that no men are saved from dying as a result of being tested.)

You might wonder what gives Prof. Ablin a right to sound off about the PSA test. Simple--he is credited as the discoverer of PSA back in 1970.

Ablin notes that despite recent major studies showing the lack of benefit from PSA screening, medical sopcieties and patient advocacy groups have been slow to change their advice on having the test. "So why is it still used? Because drug companies continue peddling the tests.... I never dreamed that my discovery of four decades ago would lead to such a profit-driven public health disaster."

So now it appears that I am doubly uninformed--I not only missed Ablin's op-ed, I also did not happen to notice that drug companies are pushing PSA testing. I don't know whether drug companies actually sell PSA test kits to labs or (more likely in my view) drug companies know that they'll sell a lot of prostate cancer drugs so long as men are stampeded into having themselves screened. (As I posted about earlier in describing how drug companies who want to sell osteoporosis drugs find it to their benefit to push bone mineral density tests: Perhaps some of the kind people who put comments on this blog know the answers and can advise us.


Jan said...

Ablin's op-ed article says "the test is hardly more effective than a coin toss." At the usual cut-off, PSA sensitivity is 20% and specificity is 94%. This is much better than a coin toss. He also talks about "painful prostate biopsies." With an anesthetic, the biopsy is not painful (ok some urologists fail to use an anesthetic). While side effects are still a concern, treatments have improved.

Ablin is worried about the cost of PSA testing. Most men are worried about what happens to them.

Howard Brody said...

Jan, I did not plan with this post to get into all the details of the debate over PSA screening, but I suppose some of it is inevitable. Ablin's article mentions cost, but among the many evidence-based physicians who have been arguing against PSA for years, their major concern is not cost but patient mortality and morbidity--how many men end up with major prostate surgery based on biopsy findings that reveal a cancer which ideally would have been left alone and would never have caused symptoms. Of the two major studies published last year in the New England Journal, one showed no benefit at all from PSA testing. The other showed a slight benefit, but that for every 1 man whose life was saved, 47 will suffer some serious harm. Men at a minimum need to be informed of those odds before they receive a PSA test. Thanks for commenting, Howard

Jan said...

Well, as a loyal reader of your blog and since you responded …, it’s my understanding that one cannot distinguish between prostate cancer that would never cause symptoms and one which would kill you. I presume that a Gleason score of 10 was once a 6? Also, there are flaws in the studies that you mention. For example, many in the “unscreened” group were tested for PSA. Moreover, going to a certain urologist web site reveals a more recent study, which is more favorable to PSA screening And surgery isn’t the only treatment option. In any case, I agree with your last statement, that men need to be informed of the risks and benefits of PSA testing.

Marilyn Mann said...

A family member is in Suburban Hospital in Bethesda, an affiliate of Johns Hopkins. I noticed today that there is a sign in the lobby urging men to "take care your health" by coming in for free prostate screening. I was more interested in getting to where I was going than investigating the sign, so I'm not sure if it was specific about what they were offering, but I assume it includes PSA testing.

Howard Brody said...

Marilyn: Despite the steady growth of evidence against routine PSA testing--the two recent NEJM articles are really just the last in a long series of reasons not to do the test-- the "cancer screening mafia" if I can be so rude as to call them that has persisted in demanding the use of the test, basically telling women that if you don't nag your husband to have this test done, you're murdering him. The basic problem is that once we label something as "cancer screening" it becomes God and motherhood and issues of evidence fly out the window. Fortunately, even the don of the mafia, the American Cancer Society, is now apparently admitting to second thoughts about PSA. Thanks for your comments, Howard

Marilyn Mann said...


Yes, I know.

stop smoking help said...

As someone who suffers a very different urologic condition, I am amazed at how little research (in comparison to other organ systems) is dedicated to urology, as a whole. It all seems very geared toward cancer yet even then, there seems to be disagreement as many MDs will say more people die with prostate cancer than from prostate cancer.

It just strikes me odd that this organ system, particularly in men, is left to fend for itself on the basis of physician's experience rather than scientific literature. Is this because drug companies indirectly or directly dictate medical studies based on their products? Outside of cancer and ED, there seem to be little uro. organ specific products for men, when there are a host of uro. diseases.