On Prostate Cancer Screening, Warren Buffett and Ignoring Science
Prostate cancer is all over the news these days.
First Warren Buffett, 81, announced to his Berkshire Hathaway shareholders that after a routine PSA test, followed by a surgical biopsy, he had been diagnosed with early-stage prostate cancer and planned to undergo a two-month course of radiation therapy.
This announcement immediately set off controversy as prostate cancer experts weighed in on Buffet’s case and bemoaned the precedent it sets. In 2008, the United States Preventive Services Task Force (USPSTF) and other medical organizations began discouraging men over age 75, and their doctors, from using the PSA test. Although it can detect silent prostate cancer, the false positive rate is high and the vast majority of these older men would die of something else in the 10 to 20 years that it would generally take for the cancer to even cause clinical symptoms.
Meanwhile, as Marc B. Garnick, professor of medicine at Harvard Medical School and a prostate cancer expert writes on the Harvard Health Blog, “Buffett’s PSA test set off a disastrous chain of events that will probably do the legendary money manager more harm than good.” Immediate side effects of radiation treatment, writes Garnick, include fatigue and bowel problems; “Over the long term, about 50% to 70% of men lose the ability to get or sustain an erection or experience rectal bleeding.” The better choice is clearly “watchful waiting”—close surveillance and treatment only when and if the cancer progresses.
Now it turns out that Buffet is far from an outlier among men over 75 who, despite recommendations to the contrary, are still getting routine PSA tests. In a research letter published today in the Journal of the American Medical Association, we discover that “Despite the USPSTF recommendation against prostate cancer screening in men aged 75 years or older in 2008, PSA screening rates did not change [in 2010].” In fact, among men 75 and older, some 43% were getting screened in 2008 vs. 44% two years later. This is higher even than the 33% of men aged 50-59 who are getting routinely screened.
In case patients and doctors haven’t kept up with the evidence, here are the undisputed facts about PSA screening and men over 75: The USPSTF gives the test a D-rating and the American Cancer Society holds that “men with no symptoms who are not expected to live more than 10 years (because of age or poor health) should not be offered prostate cancer screening.” Or as Richard Albin , one of the discoverers of PSA wrote in a 2010 op-ed piece for The New York Times, “men lucky enough to reach old age are much more likely to die with prostate cancer than to die of it.” Finally, all evidence to date has failed to demonstrate that prostate screening actually decreases mortality.
This is not news. Ablin’s op-ed two years ago noted that 30 million American men were getting the test every year at a cost of $3 billion, much of it paid by Medicare and the Veteran’s Administration. “The test’s popularity,” he wrote, “has led to a hugely expensive public health disaster.”
Otis Brawley, the chief medical officer of the American Cancer Society and an oncologist at Emory University, has been raising the alarm for years about the overuse of PSA testing and the resulting crisis of overtreatment and ensuing harm to men who undergo surgery, radiation and other interventions. In 2009 he wrote in the Journal of the National Cancer Institute : “Prostate cancer screening has resulted in substantial overdiagnosis and in unnecessary treatment. It may have saved relatively few lives.” He urged doctors to have more respect for the scientific process and scientific evidence supporting a more conservative approach. At that time, Brawley was commenting on a study by H. Gilbert Welch and Peter Albertsen in the same journal that concluded that while; “Prostate cancer incidence has increased since the introduction of prostate-specific antigen screening…Much of the excess incidence may represent overdiagnosis.”
Brawley wrote at the time; “Many men who thought their lives were saved by being screened, diagnosed, and treated for localized prostate cancer are perplexed to learn that so few benefit. They may be even more amazed that this is not a new finding. What is new is the fact that many health professionals are finally accepting it as true.”
It is now almost three years later and it seems that a significant portion of health professionals have still either not gotten the message or, more likely, have chosen to ignore it.
Why? For some doctors and patients it’s a case of unshaken belief in the power of early diagnosis. It seems that no amount of evidence or vetted research findings can convince them that PSA testing doesn’t save lives and that early treatment—no matter the physical or financial costs—is of utmost importance. For others, and I suspect this is the majority, the financial rewards of testing and treatment are driving doctors and hospitals to ignore the evidence and push onward with PSA testing—even for an 81-year-old man with no symptoms.
I return to Otis Brawley to help make this point. His new book, “How We Do Harm: A Doctor Breaks Rank About Being Sick in America” sheds a needed light on the financial conflicts that determine the kind of care we receive, and at a recent meeting of the Association of Health Care Journalists, he said that health care today suffers from “a subtle form of corruption.”
Brawley’s entire speech is available on video and his is one of the sharpest critiques I’ve ever heard of our “failed” health care system. It holds even more weight because it is coming from someone who is the voice of a seriously mainstream group; the $400 million behemoth that is the American Cancer Society. Brawley bemoans the lack of science and evidence to back up many of the most-used treatments and interventions for major ills like diabetes, prostate cancer and heart disease. He calls out drug companies, hospitals and doctors for valuing profits over patient care and calls for a greater emphasis on prevention and evidence-based care.
And then he talks about prostate cancer.
Brawley recounts an experience he had on a site visit to a hospital in 1998 while an Assistant Director at the National Cancer Institute. During the visit a marketing executive explains to Brawley the publicity value and financial rewards of a free prostate screening program offered by the hospital at a local mall. The plan is to screen the first 1,000 men over 50 who come to the mall for testing. I’ve transcribed Brawley’s recollections from the video and they provide a great explanation for the profit-driven practices that continue to occur today, 14 years later:
“If they screen 1,000 men they’re going to have 145 abnormals. They’re going to charge about $3,000 to figure out what is abnormal about these abnormals, that’s how they pay for the free screening. About 10 of the 145 won’t come to this hospital so that’s business for their competitors, but they’ll get 135 times $3,500 on average. Of the 135, 45 are going to die of prostate cancer and the other percentage are going to get radical prostatectomy at about $30-40,000 a case; there’s a percentage that’s going to get seeds at about $30,000 a case; a percentage were going to get radiation therapy that (at the time) was about $60,000. Then [the marketing executive’s] business plan goes further, he knows how many guys are going to have so much incontinence that diapers aren’t going to do it so he had in his business plan how many artificial sphincters urologists were going to implant. And then he was a little apologetic because there was this new thing called Viagra that screwed up his estimates for how many penile implants he was going to sell because guys were upset about impotence related to prostate cancer treatment.”
Brawley says, “this is 1998, I ask him, if you screen 1,000 people how many lives are you going to save? He took off his glasses and looked at me like I was some kind of fool and said, ‘Don’t you know, nobody’s ever shown that prostate cancer screening saves lives, I can’t give you an estimate on that.’”
These kinds of profit-driven screening programs continue today; radio advertisements paid for by urology practices, hospitals and other interested parties urge testing for all men and early treatment. Ads for the latest robotic surgeries, radiation therapies and other cutting edge treatments for prostate cancer—all paid for by Medicare—that earn hundreds of millions of dollars for health care providers also fill the airwaves. Testimonials from men whose lives were “saved” by testing and early treatment feed the natural desire for consumers to believe in the benefits of testing and technology. Until we begin to create disincentives for testing and treatment that is unnecessary, wasteful and harmful, while at the same time rewarding doctors who provide evidence-based care, our health care system will continue to be “corrupted”.