Medicine
At first blush, inappropriate health care sounds like a contradiction in terms. Isn't "care" by definition something that is necessary and appropriate, and if so, how is it possible to get too much? Such talk inevitably invites accusations of "rationing," drawing unfavorable comparisons to the United Kingdom's National Institute for Health and Clinical Excellence (NICE), an agency that determines whether or not to pay for benefits in the UK's government health system, based on clinical and cost-effectiveness standards. Cost-effectiveness is an important issue that both sides of the health reform debate have unfortunately not addressed, but inappropriate health care isn't necessarily expensive care. It's care that does nothing to improve your health.
Although many preventive health services (screening tests and counseling for health behavior change) have been shown to improve quality and length of life, many remain unproven or are associated with significant harms. In particular, screening for prostate cancer with the prostate-specific antigen (PSA) test, which has been performed on millions of American men since it became common medical practice in the early 1990s, is often inappropriate. While the potential benefits of PSA screening (fewer deaths from prostate cancer) are still being debated by experts, the harms - diagnosing slow-growing tumors that would never have caused symptoms or affected health - are no longer in doubt.
A recent study in the Journal of the National Cancer Institute shows why. Some experts have argued that the decline in the prostate cancer death rate seen in the U.S. over the past 2 decades proves that screening and early detection are saving mens' lives. Assuming that this were true, the authors calculate that for every life saved by screening, more than 20 men had to be diagnosed with prostate cancer (and more than 75% of these men chose to be treated with surgery or radiation).
Let me put this information in plainer terms. If you were told by your doctor that having the PSA test could lead to detection of prostate cancer, but that 19 times in 20, treatment would make no positive difference to your health, would you choose to have this testing? (In fact, the number may be as high as 47 in 48, according to a recent European study.) Consider that up to half of all men who are treated for prostate cancer experience erectile dysfunction or urinary incontinence. Unfortunately, this message isn't getting through to clinicians or patients - more than 75% of U.S. men over 50 have had at least 1 PSA test in the past 3 years. By any measure, that's too much health care.
- Psa Screening: “one Of Medicine's Great Success Stories"?
. Guest blog by Robert Ferrer, MD MPH I spent 2 days at home recently with the H1N1 flu and caught up on some of my newspaper reading. In the Oct 11, 2009 New York Times Magazine, (p.38) was an advertising supplement, "Health and Wellness Outlook Special...
- Psa Screening: What Is The Value?
Two studies published in the New England Journal of Medicine on line on March 18, 2009 regarding the use of prostate-specific antigen (PSA) screening for prostate cancer have been getting a lot of coverage in the popular media, including NPR and the New...
- Two Perspectives On The Psa Screening Pendulum
Two research studies published earlier this week in JAMA presented compelling evidence that the 2012 U.S. Preventive Services Task Force recommendation statement that discouraged prostate specific antigen (PSA)-based screening for prostate cancer...
- We Need To Know More About Psychological Harms Of Screening
Several years ago, a few colleagues and I performed a systematic evidence review to help update the U.S. Preventive Services Task Force's recommendations on screening for prostate cancer. One of our key questions asked about the harms associated with...
- Challenging Conventional Clinical Wisdom
Over the past few years, I've been invited to speak twice at Lancaster General Hospital (PA) about studies of the effects of screening for colorectal and prostate cancer. Recognizing the need to further explore the controversies surrounding the evidence...
Medicine
What is "too much" health care?
At first blush, inappropriate health care sounds like a contradiction in terms. Isn't "care" by definition something that is necessary and appropriate, and if so, how is it possible to get too much? Such talk inevitably invites accusations of "rationing," drawing unfavorable comparisons to the United Kingdom's National Institute for Health and Clinical Excellence (NICE), an agency that determines whether or not to pay for benefits in the UK's government health system, based on clinical and cost-effectiveness standards. Cost-effectiveness is an important issue that both sides of the health reform debate have unfortunately not addressed, but inappropriate health care isn't necessarily expensive care. It's care that does nothing to improve your health.
Although many preventive health services (screening tests and counseling for health behavior change) have been shown to improve quality and length of life, many remain unproven or are associated with significant harms. In particular, screening for prostate cancer with the prostate-specific antigen (PSA) test, which has been performed on millions of American men since it became common medical practice in the early 1990s, is often inappropriate. While the potential benefits of PSA screening (fewer deaths from prostate cancer) are still being debated by experts, the harms - diagnosing slow-growing tumors that would never have caused symptoms or affected health - are no longer in doubt.
A recent study in the Journal of the National Cancer Institute shows why. Some experts have argued that the decline in the prostate cancer death rate seen in the U.S. over the past 2 decades proves that screening and early detection are saving mens' lives. Assuming that this were true, the authors calculate that for every life saved by screening, more than 20 men had to be diagnosed with prostate cancer (and more than 75% of these men chose to be treated with surgery or radiation).
Let me put this information in plainer terms. If you were told by your doctor that having the PSA test could lead to detection of prostate cancer, but that 19 times in 20, treatment would make no positive difference to your health, would you choose to have this testing? (In fact, the number may be as high as 47 in 48, according to a recent European study.) Consider that up to half of all men who are treated for prostate cancer experience erectile dysfunction or urinary incontinence. Unfortunately, this message isn't getting through to clinicians or patients - more than 75% of U.S. men over 50 have had at least 1 PSA test in the past 3 years. By any measure, that's too much health care.
- Psa Screening: “one Of Medicine's Great Success Stories"?
. Guest blog by Robert Ferrer, MD MPH I spent 2 days at home recently with the H1N1 flu and caught up on some of my newspaper reading. In the Oct 11, 2009 New York Times Magazine, (p.38) was an advertising supplement, "Health and Wellness Outlook Special...
- Psa Screening: What Is The Value?
Two studies published in the New England Journal of Medicine on line on March 18, 2009 regarding the use of prostate-specific antigen (PSA) screening for prostate cancer have been getting a lot of coverage in the popular media, including NPR and the New...
- Two Perspectives On The Psa Screening Pendulum
Two research studies published earlier this week in JAMA presented compelling evidence that the 2012 U.S. Preventive Services Task Force recommendation statement that discouraged prostate specific antigen (PSA)-based screening for prostate cancer...
- We Need To Know More About Psychological Harms Of Screening
Several years ago, a few colleagues and I performed a systematic evidence review to help update the U.S. Preventive Services Task Force's recommendations on screening for prostate cancer. One of our key questions asked about the harms associated with...
- Challenging Conventional Clinical Wisdom
Over the past few years, I've been invited to speak twice at Lancaster General Hospital (PA) about studies of the effects of screening for colorectal and prostate cancer. Recognizing the need to further explore the controversies surrounding the evidence...