Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Article Comments (3)

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*


You may also like these posts

Read comments »


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.

Return to article »

Latest Interviews

Caring For Winter Olympians In Sochi: An Interview With Team USA’s Chief Medical Officer Dr. Gloria Beim

I am a huge fan of the winter Olympics partly because I grew up in Canada where most kids can ski and skate before they can run and partly because I used to participate in Downhill ski racing. Now that I m a rehab physician with a reconstructed knee I…

Read more »

How Do Hospital Executives Feel About Locum Tenens Agencies And Traveling Physicians?

I recently wrote about my experiences as a traveling physician and how to navigate locum tenens work. Today I want to talk about the client in this case hospital side of the equation. I ve had the chance to speak with several executives some were physicians themselves about the overall…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

Latest Book Reviews

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

Read more »

See all book reviews »