USPSTF Recommends Against Prostate Cancer Screening

Today’s Managing Health Care Costs Indicator is $3 billion

Word leaked late last week that the US Preventive Services Task Force (USPSTF) will recommend against prostate cancer screening with the prostate specific antigen.  The evidence has been piling up for years that routine PSA screening doesn’t save lives – and the cost, morbidity and early death from treatment, and incontinence and erectile function problems caused by this screening are enormous.  This is the link to the USPSTF draft recommendation, which rates prostate cancer screening a “D” (moderate or high certainty that the intervention harms, has no benefit, or harms outweigh the benefits). 

The problem with prostate cancer screening is not only that there are many false positives.  More importantly, there are many true positives that find cancer that would have had no impact on the patient’s life span or quality of life.  A man whose prostate cancer would never have hurt him who has this treated is always worse off!   The scientist who discovered PSA, Richard Ablin, editorialized against its use in screening in 2010.

Prostate cancer treatment is big business, too.  Urologists and radiation therapists make a substantial portion of their income from prostate cancer treatment, and hospitals and physician groups have made huge capital investments in IMRT (intensity modulated radiation therapy) and even proton beam therapy centers. 

Shannon Brownlee, author of “Overtreated” (see bottom of web page for book description) has a thoughtful and well-timed article in the New York Times Magazine today about this difficult issue.  She asks “Can Cancer Ever Be Ignored?”  She reports that the USPSTF was ready to release its finding on PSA screening in 2009 – but the blowback from the suggestion that year that mammography should not be routinely recommended for women between 40-50 delayed the recommendation. It was again delayed before the 2010 midterm elections – and even now the report was put out in draft form only after the content was leaked in the press.  

This draft recommendation is finally published even as a separate investigation suggests that 40% of the cancer screening ($1.9 billion)  services paid for by Medicare are medically inappropriate.  This report only considered PSA screening inappropriate in men over 75. If all PSA screening was considered in appropriate, the portion of cancer screening that is inappropriate would be substantially higher. 

There are some screening tests that improve the quality of health care – including pap smears and mammograms for women between 50 and 69.  There is evolving evidence that CT scans might appropriate for screening those at high risk of lung cancer, although the literature on this is not yet fully settled. 

It’s reassuring to think we can save lives (and money) by screening.  This is true less often than we would wish. 

PSA Scorecard

$3 billion spent on PSA screening annually

1 million men treated with surgery, radiation therapy or both who would not have been treated without PSA testing

5000 deaths shortly after surgery

10-70,000 major complications

200-300,000 cases of impotence, incontinence, or both

 Source 

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Screening CTs for Lung Cancer

Today’s Managing Health Care Cost Indicator is $674,000

Last week’s New England Journal of Medicine  reported a landmark study showing that screening low-dose CT scans really can save lives in people at high risk for lung cancer. 

The study is unequivocal – those who got screening CT scans were substantially less likely to die of lung cancer. Further, all-cause mortality was lower – even though a few people with CT scan screening died of exploratory surgery when they were found not to have cancer.

This study enrolled only smokers or ex-smokers with at least 30 pack years of smoking history, and excluded those who had signs or symptoms of cancer already, such as weight loss or coughing up blood.   It was peformed by the National Cancer Institute, and did not have funding from either companies that manufacture scanners or from tobacco companies.

The authors don’t recommend that all smokers and ex-smokers start getting annual CT scans.   Even with low dose scans, some cases of cancer are likely to result from massive screening – especially breast cancer in women. 

The level of “false positives,” abnormal CT scans that did not represent lung cancer, was stunningly high.  Over a quarter of study participants were found to have a scan suspicious for cancer in years one and two, and almost one in six in year three.  Only 1 in 20 abnormal CT scans suspicious of cancer actually showed a cancer. The control group received annual chest radiographs, and the CT scan group had a total of 119 excess cancers found – out of  18,146 suspiciously abnormal scans over the three year screening cycle.  That’s an increased case finding rate of 0.66% for the CT group compared to the radiography group.

Here’s the big public policy problem.   This study included 3 CT scans (at annual intervals) for just under 27,000 patients. At $1000 per scan, that would be a cost of over $80 million for the scans alone.  The cost of workup of all those false positives was substantially more.    The cost of just scans per incremental cancer found would have been $673, 664! ($80 million divided by 119) 

This study shows clearly why screening is unlikely to save dollars in the health care system.  The study took a group of high risk individuals – and even in this group, the false positive rate was quite high, and the cost per additional case found was very high.   

From a public policy perspective, we have to either

1)     Get scans that cost $100, rather than $1000.  We’ll need major disruptive innovation to allow that.

2)     Develop a more specific screening test, without losing sensitivity – so there won’t be 19 false positives for every true positive

3)     Develop less invasive followup tests to minimize the cost of pursuing the many abnormal tests

Of course, the best approach is to continue to levy high taxes on cigarettes, reinvigorate counter-marketing, and make cigarettes difficult for teenagers to obtain.  

Screening for lung cancer is not nearly as good as preventing lung cancer – and screening is far, far more expensive.

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Illusory Promises of Future Health Care Cost Savings (and Increased Profits for Osteoporosis Screening Now!)

Click on image to enlarge it. Source 

The Boston Globe today has an excellent exploration of how lobbyists inserted language in the health care reform bill to effectively double payment for bone densitometry.   Medicare recognized that it was overpaying for osteoporosis screening tests, and cut prices.  Lobbyists for the scan manufacturers, physicians who perform scanning, and drug companies which sell osteoporosis medication cried "foul." As a result of a $3 million lobbying effort,  the price for a scan will go up from $50 to $97.


Here are two comments from (Democratic) legislators who got campaign contributions from the scanning industry and inserted this language into the health reform bill:


Representative Shelley Berkley (D-Nevada)

“You have to view these things through common sense. And it doesn’t take a genius to figure out that providing bone density tests for elderly Americans will save this country billions of dollars,’’ said  Berkley. “In addition to saving taxpayers money, it will prevent suffering that people with osteoporosis have.’’


Senator Blanche Lincoln (D- Arkansas)
“Part of her effort to strengthen and improve Medicare includes recognizing when a particular test with enormous potential to prevent health problems and significant promise of cost-savings is being taken out of doctors’ offices because providers can’t afford it,’’ said Lincoln spokeswoman Marni Goldberg. “That’s a flaw in the system that needs to be addressed.’’


The article notes that the cost of osteoporosis-related fractures is $19 billion per year. 


Both of these representatives are just plain wrong.   We should screen women at risk for osteoporosis - so that we can prevent fractures, prevent premature death, and give these women (and some men too) more Quality Adjusted Life Years (QALYs).   


However, when we make screening more available it costs more money.  It does not save money. In fact, depending on the analysis, each QALY saved by screening costs between $55,000 and $450,000.   Nothing wrong with doing screening.  But we should not offer false hope that this screening will save billions of dollars. 

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Prostate Cancer Screening: Rough Estimate of the Cost

Two studies in last week’s  New England Journal Of Medicine showed disappointing results from prostate cancer screening. This is a reminder that investments in preventive care are not always a good idea.  The United States study, completed in 10 centers, included 77,000 patients and showed a nonsignificant increase in death rates among those patients who were randomly assigned to screening.  The European study, an amalgam of seven different studies which had different designs, included 182,000 patients, and did show a decrease in death from prostate cancer of 7 per 10,000. However, 49 men were treated for prostate cancer for each life saved – leading to an enormous amount of incontinence and impotence. 

 

I’ll turn 50 next year – and it’s not looking like I’ll be getting my first PSA test!

 

The morbidity from all prostate cancer treatment is considerable – whether prostate removal (radical prostatectomy) or radiation (either external beam or implantation of radiation ‘seeds’).  There is has been little written about the cost of the increased cancer diagnosis from  prostate cancer screening – so I figured I would provide some “back of the envelope” guesstimates of the cost of our prostate cancer screening.

 

Population:  18.7 million  ages 50-59 (United States)

Increased Cancer Diagnoses: 3.4% (8.2% in the screening group and 4.8% in the control group)

è Increased Cancer diagnoses: 638,542 for this population over about a decade

 

Distribution of Treatment (and associated cost)

Wilson, et al Cumulative cost pattern comparison of prostate cancer treatments, Cancer 109: 18-527

Note that this is Medicare data, so this understates the cost compared to a population under 65.

 

è Total excess cost over 10 years for this population: $27 billion

 

That’s not a trivial figure even in these days of massive corporate bailouts.

 

	%age	Cost	#	Spend
Radical Prostatectomy	55%	$        36,888	350,055	$  12,912,828,840
Cryotherapy	3%	$        43,108	18,933	$        816,163,764
Brachytherapy	15%	$        35,143	93,684	$    3,292,336,812
External Beam	9%	$        59,455	57,360	$    3,410,338,800
Androgen	13%	$        69,244	85,129	$    5,894,672,476
Watchful Wait	5%	$        32,135	33,378	$    1,072,602,030
TOTAL INCREASED SPENDING				$  27,398,942,722

 

  

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