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“It’s cancer … an aggressive form. It’s metastasized. We can’t cure it, but we can treat it.”
In 2012, seven-plus years before that diagnosis, I’d read articles questioning the value of prostate cancer screening. At my regular annual physical, I asked my doctor whether he would do a PSA test, as other doctors had done for over a decade.
He pivoted his monitor to me. The image was of 100 little blue silhouettes of men. He stated that very few men (those shaded in gray) die of prostate cancer. The vast majority would die from other causes. He said the harms of screening outweighed the benefits, but added derisively, “I’ll do it if you want.” I got the message; a test wasn’t done.
Years later I learned the U.S. Preventative Services Task Force (USPSTF) issued definitive guidelines in 2012 not to screen for prostate cancer. It said knowing about prostate cancer led to treatments that didn’t extend life, but harmed men who underwent prostatectomies. They concluded that it was better for doctor and patient alike to not know if any patient had prostate cancer. In part, what drove this conclusion was a 2008-09 Health and Human Services (HHS) study of prostate cancer as a cost driver in medical care. The study concluded that PSA testing leads to overdiagnosis and overtreatment. That conclusion was fed to the USPSTF, whose guidelines disregarded the fact that 10-20% of men may have an aggressive form of cancer — a cancer that can kill. Those men become collateral damage to a guideline that seeks to protect the other 80-90%.
Most men with prostate cancer will indeed not die principally of prostate cancer. However, those with an aggressive form may see their lives shortened by five to seven years or more, and undergo harsher, more costly treatment, assuming their cancer is even caught. In the seven years after the 2012 guidelines were issued, fewer prostate cancers were diagnosed and treated. Yet the rate of aggressive cancers diagnosed rose at the rate of 4-7% a year. Because fewer prostatectomies were done, there were some cost savings. However, those cost savings were offset by the cost of treating aggressive cancers, which can be orders of magnitude greater. Moreover, those with aggressive forms suffer the same or greater quality-of-life issues as men treated surgically, while likely having shortened lives.
In 2018, the USPSTF reversed its flawed 2012 guidelines. In what became known as “shared decisionmaking,” the burden of deciding on screening is now put on patients. This sleight-of-hand gives primary-care physicians deniability for any harm to patients. Patients would be the final arbiter of whether to screen, after only a brief discussion in a rushed 15-minute appointment.
