While I agree with your concerns about massive screening and false positives, I completely disagree with your conclusion -- that having a distant committee of bureaucrats and academics deciding appropriateness is the way to address it.

We have been doing that for years with third-party payers making "medical necessity" decisions and having a financial incentive to deny coverage. It hasn't worked. And it won't work any better if you inject politicians into the process.

Far better to let the end-using consumer control the money and make his own decision about the best use of those funds. They won't be so eager to embrace these invasive procedures, and they will want to know about less costly alternatives.

Greg Scandlen
Consumers for Health Care Choices

I fully agree that Rudy (and his friends with the usual faith-based "science") should be skewered.

But I am wondering about some of the assertions about PSA-testing and its consequences. I know many men have biopsies (no picnic) and a high percentage are apparently "false postives." (You have to say "apparently" because biopsies can "miss" and end up being false negatives.) But are there really specialists who "operate, chemically castrate, or radiate" based on PSA alone, with no confirming biopsy?

(Even if one has the latter, there are further considerations re: what to do, if anything. Just wanting to be sure we're all on same essential page.)

Prostate cancer screening could indeed be a poster child for (among other many other troubling things) the problem with our national obsession with technology in medicine, as well as an example of how popular mythology ("how could it be anything but terrific to find cancer early?!") is not only terribly misleading, but can also lead to real harm. It can also provide a wonderful model for the concept of "shared decision making" between (well-informed) doctors and patients. But while I agree that members of the public can (must) be taught about this, I'm far less sanguine that it can be done in 650 words. For anyone interested in truly learning about this particular medical issue, and its many complexities -- it requires perhaps a half hour or so, rather than either the 5 minutes it takes to read an op-ed, or 4 years of medical school -- I would refer you to the patient (and physician) education project being led by Professor Michael Wilkes, at UC Davis Medical School.

One further comment -- I strongly agree with your proposed effectiveness institute (similar to something Shannon Brownlee suggests at the end of her excellent new book, "Overtreated ..."), and encourage readers to resist the reflex visceral reaction that is intended to be aroused as soon as the specter of (federal) 'bureaucracy' is raised. Of course federal appointees can do a terrible job (look at just about any of our current healthcare agencies) -- but they COULD also do an excellent one. Simply creating an institute, and then allowing it to function as the servant of proprietary interests, or overarching political philosophy -- rather than on behalf of science and the public health -- is indeed a recipe for disaster. But that surely doesn't mean that the concept itself is inevitably flawed, or that -- in its best iteration -- it isn't something we should work for.

The term "false positive" is somewhat misleading here. Cancer comes in many forms, which you can categorize as birds, bears, and turtles according to how fast they grow and how likely they are to metastasize, or spread throughout the body. Birds are fast growing tumors and highly likely to metastasize. Bears are slower growing, and they may never metastasize, and might not even cause symptoms, depending upon how old the patient is when the tumor forms. The turtles are called "indolent" tumors; they're so slow growing they probably would never cause a single symptom even if they were never detected and treated.

Many prostate cancers are turtles or bears. The problem is, even a biopsy isn't very good at distinguishing between the different types of prostate cancer, so once any kind of cancer is detected, most physicians and patients want to surgically remove it.

That wouldn't be a problem is the treatment were benign, but it isn't. Prostate surgery is a big deal, and it leaves a significant number of men incontinent, impotent, or both -- which is why we should all be investing in Depends and Viagra stock.

This has two consequences for the current political discussion. One, in the U.S. we know with absolute certainty we're overtreating huge numbers of men for cancers that would never have bothered them in their lifetimes. And we're doing it becuase we screen for prostate cancer using the PSA test. We think that catching cancer early is a good thing, but in this case, we're catching a whole lot of cancers that don't need to be treated -- and then we're treating the daylights out of them with surgery that has a major impact on men's lives.

Two, when we compare five year mortality rates in the U.S. and the U.K., their five-year mortality rate is automatically going to be worse because they don't screen for prostate cancer nearly as much as we do. that means that men who come in to be treated for prostate cancer actually have a cancer that is symptomatic.

One way or another, either Rudy Giuliani's medical consultants don't understand how screening and mortality statistics work, or they are deliberately lying to score political points.

One screening that is grossly under-utilized is colorectal cancer screening.

Screening has increased in people who have insurance, but not in un- or under-insured. Congress is considering a couple of programs that would increase screening in these areas.

My 2 cents: Get your butt screened. Push researchers to improve screening techniques for prostate and lung cancer.

www.CoverYourButt.org

I am assuming Shannon's book, and other studies, have the relevant big numbers. We all know a zillion anecdotes. Two friends of mine recently had relatively low PSAs, both in absolute number (under 4 in one instance; under 2 in the other) and also relatively low velocity and nothing on DRE, who had urologists whose "instinct" was to biopsy. In both instances, they turned out to have the fast-growing, "bird" tumors. No extant guidelines, as far as I know, would have suggested biopsy under their circumstances. So they were the "lucky outliers," as it turned out.

But anecdotes are mostly (but not entirely) beside the point. It does seem we are agreed that no one operates based on PSA alone; that biopsy results (including Gleasons) are rarely without ambiguity); that developing reliable guidelines is enormously complex, both in general and for particular pts.