A urologist’s hypocrisy on prostate cancer screening

I am furious.

For anyone hiding under a rock the last year or so, the latest recommendations about prostate cancer screening have changed from earlier iterations of “screen everyone with a prostate with a PSA (prostate specific antigen) and a DRE (digital rectal exam, where the “digital” equipment referred to is a finger) every year” to don’t do it at all.

The United States Preventive Services Task force reviewed the literature and came to the conclusion that routine prostate cancer screening does more harm than good, and should not be done. Hear the emphasis on routine. In men with a urinary problem suggestive of prostate cancer, certain men with worrisome family histories for the disease and so forth, the above does not apply. We’re talking about blindly screening all comers. And the bottom line is this: don’t.

Screening is to be offered to patients in the context of “shared decision making,” involving a detailed discussion between doctor and patient about the pros and cons of screening (generally PSA testing).

Great. No problem.

Here’s the thing, though. I just had a patient come back from a urological consult for a problem that had nothing to do with the prostate with an order for a PSA. Oh, I said. Did you have a detailed discussion with the urologist about the pros and cons of PSA screening for prostate cancer?

No.

What did the urologist say to you?

“He said that there were no urologists on the panel that made that recommendation.”

It’s a non sequitur of an ad hominem, perilously close to the barely disguised antisemitism that  discounts evidence of any medical advantages of circumcision.

But it’s the urologist’s hypocrisy that infuriates me the most. If he attributes the negative recommendation to the lack of urological involvement in the guidelines, perhaps he should check out his own specialty’s guidelines:

Guideline Statement 1: The Panel recommends against PSA screening in men under age 40 years. 

Guideline Statement 2: The Panel does not recommend routine screening in men between ages 40 to 54 years at average risk. 

Guideline Statement 3: For men ages 55 to 69 years the Panel recognizes that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, the Panel strongly recommends shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man’s values and preferences. 

Guideline Statement 4: To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce overdiagnosis and false positives.

Guideline Statement 5: The Panel does not recommend routine PSA screening in men age 70+ years or any man with less than a 10 to 15 year life expectancy. 

Reading the whole thing is pretty informative. Urologists should try it.

Annual PSAs on everyone from age 40 generate gobs of abnormal results, leading to biopsies galore and of course a plethora of early cancer diagnoses. “We offer watchful waiting,” they say. But once a patient hears the word “cancer,” they stop listening and start screaming, “Get it out!”

See, urologists treat prostate cancer. Find it, cut it out, nuke it, whatever it takes. Never mind that the patient would never have had symptoms from a disease that was never going to kill him. It’s cancer.

But I treat patients, men who end up incontinent and impotent from overzealous treatment by those same urologists who impugn preventive care recommendations because there are no urologists on the panel, but who can’t be bothered to follow their own fundamentally similar specialty guidelines.

Guess what. There are no foxes on the panel developing guidelines for guarding henhouses either.

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.

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  • Rob Burnside

    I’ve often compared the “weird science” of PC treatment to buying a used car– from the proverbial back row. At least that’s the way it sometimes seems now, from the patient’s point of view. But help (in the form of better diagnostic testing) is on the way. I’m not quite as worried for my son, and I’ve made up my mind to just stay tuned. Blogs like yours are vital. Thanks for a very well-written piece!

  • DinoDocLucy

    Read again: “Discounting EVIDENCE OF MEDICAL ADVANTAGE” of circumcision is often rooted in antisemitism. Nothing wrong with an uncircumcised penis. But antisemitism is often the hidden agenda for ignoring/downplaying EVIDENCE of decreased risk of HPV, HIV, and other infections provided by circumcision.

    • buzzkillerjsmith

      Circs are not a scam.

      Next case.

  • buzzkillerjsmith

    PSAs are a scam. My opinion of urologists is in the toilet.

    Next case.

  • Kaya5255

    At the risk of sounding cynical, I firmly believe that most “recommended” screening tests are flawed. Far too many consumers are subjected to expensive and unnecessary procedures that ultimately have little value in relationship to the care they receive.
    I’m very good at saying, “no”!

  • drjoekosterich

    Love the foxes and hens analogy. All screening tests have risks. Those who provide treatment always benefit

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