Friday, March 12, 2010

Give them the finger, but not the needle!

The pressure to abandon costly but clearly ineffective biomedical testing is always a battle with vested interests, and shows why science is by no means just a matter adjudicated by the 'facts'. A recent example, that we've remarked on briefly before, is PSA testing to detect prostate cancer in men.

The test itself is mostly painless (a needle-prick for a small blood sample, and a budget-prick to pay the Pharma that makes the test). But it is too non-specific and greatly over-diagnoses prostate cancer. First, because it is not specific to cancer, it gives alarm where there's no need. Second, many if not by far most prostate cancers go away on their own or grow so slowly that something gets the guy before the cancer does. Third, a positive PSA reading leads to invasive and reportedly painful tests that thus have their own costs and risk, including psychological ones as well as risks of impotence or incontinence, and so on.

The alternative test is euphemistically known as the DRE ('digital rectal exam'....or finger up the rear). This can directly detect enlarged prostates (almost universal in aging men) and suggest when some other follow-up test might be called for--often the PSA.

But the most prestigious medical journals are now calling for a stop to routine testing in men over age 50, and even the guy who discovered PSA as a molecule specifically produced by the prostate gland and that circulates in the blood, is calling this a human health disaster, in a NYTimes op-ed piece. But, just as vested interests slammed last fall's recommendation by the US Preventive Services Task Force that mammography be done less frequently than current practice, those who profit from PSA testing, and follow-up tests and treatment, are standing firm in supporting its continued use.

It's always a battle when evidence-based recommendations disagree with vested interests. Health care is big business, so that the bottom-line is always on top, and always must be, as a duty to shareholders, the primary consideration when decisions about practice are made. This is as true when withholding treatment is best for the bottom-line, as for insurance companies (which, of course, is why they cherry pick their customers, refusing to cover people with 'pre-existing conditions' because they might cost money), as when testing enriches those who do the testing, such as doctors with stakes in the testing lab. And, when testing is state-of-the-art, a physician has to be pretty confident when he or she chooses not to order it, as that may risk a law suit.

Pity the poor physicians! Even those trying to be up to date and do their best, without any conflicts of interest with labs or drug companies. Which pain in the butt should get priority--the finger up the back of their patients or the patient's lawyer on their back? For a client--er, we mean a patient--over 50, they have to ask themselves whether or not to order a PSA test. It's very hard and takes the doctors' rather than the patients' guts to say no, and make the gamble that nothing will turn up later. Or to have a positive test and tell the patient just to let things ride. And what medical literature should they take seriously, when they are too busy to read much of it carefully, much less being reasonably expected to be able to actually judge the quality of the research? Should they pay any attention to the drug detail-men, or what they hear at the Pharma's expense at their 'education' conferences in the Caribbean?

This will all get more problematic when their HMO is run by a wonk with an MBA in cost-effective procedure management, and the MD is in the office trying to care for an actual human being (the patient, seen by the boss as a customer number). Who's 'evidence' will be used? Who will decide? Some are actually trying to do this right, but clearly not everyone is.

So when you get told to have your test.....what will you do: refuse to bend to the system, or just bend-over?

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