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The Fixation On A Flawed Cancer Screening Test

In the face of accumulating evidence and a U.S. Preventive Services Task Force finding that PSA screening for prostate cancer does more harm than good, the most frequent response I hear from physicians who continue to defend the test is that PSA is all we have, and that until a better test is developed, it would be “unethical” to not offer men some way to detect prostate cancer at an asymptomatic stage. (However, these physicians for the most part don’t question the ethics of not offering women screening for ovarian cancer, which a recent randomized trial concluded provides no mortality benefit but causes considerable harms from diagnosis and treatment.)

I’m currently reading historian Stephen Ambrose’s dual biography of Oglala Sioux leader Crazy Horse and Civil War cavalry general George Armstrong Custer, whose troops were routed by the Sioux at the famous Battle of Little Bighorn in 1876. One premise of the book is that the same aggressive instincts that served Custer so well during the Civil War – to always attack, even when the strength and disposition of his enemy was unknown – became fatal flaws when he became an “Indian fighter.” For most of his post-Civil War career, Custer and his men blundered around the Great Plains looking for someone to fight, and not particularly caring if the Indians he engaged in battle were actually at war with the U.S. Army. In one telling description of Custer’s first major Western engagement, Ambrose writes:

Here was audacity indeed. … Custer had no idea in the world how many Indians were below him, who they were, or where he was. His men and horses were exhausted. … He was going to attack at dawn from four directions at once. He had made no reconnaissance, held nothing back in reserve, was miles away from his wagon train, and had ordered the most complex maneuver in military affairs, a four-pronged simultaneous attack. It was foolish at best, crazy at worst, but it was also magnificent and it was pure Custer.

If readers of American Indian descent will kindly forgive my making this analogy with their 19th century ancestors, this passage is strikingly similar to the way we diagnose and manage prostate cancer. The vast majority of American Indians by this time had either signed peace treaties or were content to leave settlers alone. Under pressure to “do something” about a few troublesome tribes, however, the U.S. Army sent the overaggressive Custer out to do battle with whatever “warriors” he could find, assuming that in the process he would either kill, capture, or scare off those who aimed to do them harm.

That’s pretty much what we do by deploying the PSA test to screen for prostate cancer. We cast as wide a net as possible, doing harm at every step of the way: false positives, adverse effects of prostate biopsies, and overdiagnosis and overtreatment of abnormal-appearing cells that we identify – usually inaccurately – as potentially lethal. For every man whose life may be extended by treatment, 30 to 50 will be treated for no benefit, and 10 to 20 will sustain permanent physical harm. And our continuing obsession with this flawed screening test not only flies in the face of evidence, it’s pure Custer.

*This blog post was originally published at Common Sense Family Doctor*


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3 Responses to “The Fixation On A Flawed Cancer Screening Test”

  1. Doctorsh says:

    The PSA test is just that, a test. What you do with it is more important than the result. In my practice this test has found cancer at an early and curable stage on many occasions. So large studies are not always useful for individual situations.
    I will continue to screen with the PSA test.

  2. medicalcontrarian says:

    Doctorsh,

    Your obliviousness to your own ignorance is scary. Using such logic, how do you counsel your patients?

    ” In my experience this is a useful test. Don’t worry about those large studies which call into question that it will benefit you in the slightest and the inventor of the test who has issued a public apology for developing this test.”

    I use a coin flip which is equivalent in terms of it predictive capabilities.

  3. Ben says:

    Doctorsh, I agree that PSA is just a test, but I am curious what you do with the results of a PSA test. The problem here is that the PSA results prove counter-productive because all of the follow-up options are bad. Abnormal results give you two options: 1) run follow up tests and look towards treatment which we know do more harm than good; or 2) do nothing because we know that further treatment options tend to do more harm than good. Thus there question becomes: “given than knowing PSA levels condemns us to doing nothing or something worse than nothing, why run the test?”… you’ll do a great job terrifying your patient without any statistically acceptable treatment options.

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Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

Click here for a musical take on over-testing.

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