PSA Tests and Mammograms; Are They (Cost) Effective?

From the NEJM Oct 26, 2011 a review of the idiosyncracies of PSA testing. Most importantly:

Using data from the European screening trial, researchers have estimated that $5.2 million would have to be spent on screening (and the interventions that follow it) to prevent one death from prostate cancer. (Medicynical emphasis) That estimate does not appear to include the costs of excessive serial PSA testing and repeated office-based encounters devoted to discussions about screening or interpretation of fluctuating PSA results. The extraordinary time, effort, and costs associated with the PSA-screening enterprise must be evaluated against other claims on health care spending and physicians’ time and energy. We believe that the current PSA-based screening paradigm does not compare favorably with competing health care priorities.

Adding to the critical view of screening was the recent NY Times magazine review Can Cancer Ever Be Ignored? The article notes:

Patients and their doctors are now faced with radically polarized views about the logic of routine testing. On one side are physicians like Mohler, who argue that the test can reduce a man’s chances of dying of prostate cancer, plain and simple. This side of the debate is passionate, backed by the persuasive conviction of men who have survived prostate cancer and well financed by the multibillion-dollar industry that has grown up around the testing and treatment of the disease.

The other camp makes a less emotionally satisfying argument: on balance, scientific studies do not support the claim that screening healthy men saves lives. Screening, Brawley and others argue, can lead healthy men into a cascade of further testing and treatments that end up injuring or even killing them. As Richard Ablin, who discovered a prostate-specific antigen, put it in an Op-Ed in The New York Times, using the P.S.A. test to screen for cancer has been “a public health disaster.”

What appears to be proven by two large studies of PSA published in 2009 is that there is no difference in deaths in groups of patients receiving PSA and those not receiving it. It appears that while there is reduced mortality from prostate cancer, there is increased mortality from other causes possible from the complications of the diagnostic procedures.

An analysis of six studies of screening involving nearly 400,000 men, published last year in the British medical journal BMJ, found no significant difference in overall mortality when screened men were compared with controls. Philipp Dahm, a professor of urology at the University of Florida College of Medicine and lead investigator for the analysis, says the study shows that P.S.A. screening “does not have a clinically important impact” on overall mortality.

There have been similar concerns raised about breast cancer screening:

A new analysis of mammography concluded that while mammograms find cancer in 138,000 women each year, as many as 120,000 to 134,000 of those women either have cancers that are already lethal or have cancers that grow so slowly they do not need to be treated.

And:

The problem is that the benefit is tiny and expensive. A recent cost–benefit analysis showed that adherence to the current guidelines from the American Cancer Society costs more than $680,000 per quality-adjusted life-year (QALY) gained, as compared with a proposed alternative costing only $35,000 per QALY. Statistician Donald Berry has calculated that for a woman in her 40s, a decade’s worth of mammograms would increase her lifespan by an average of 5 days — and this survival advantage would be lost if she rode a bicycle for 15 hours without a helmet (or 50 hours with a helmet).5 The key issue here, however, is that these figures represent population averages. For the small number of women whose lives are saved, the difference is literally as large as that between life and death.

It should be also noted that much of widely publicized improved outcomes of cancer treatment today can be attributed to earlier diagnosis of the disease (lead time bias); and from finding lesions that would not grow and spread not treatment.

In the end more judicious use of screening and finding ways to cut the cost of same would improve the value of such testing without adversely affecting outcomes.

For example: one solution is to cut the price of the test from its current $70 to $$400 (including phlebotomy costs) to a more reasonable amount ($10-20). Economies of scale and efficiency would increase the value (in a cost-effectiveness sense) for this test. Charging anywhere from $25 to $150 for phlebotomy, as is the current practice, seems excessive as well.

In breast cancer screening one approach would be to delay routine screening from 40 to 50 years of age. Which as noted by Susan Love:

“I really don’t think we should be routinely screening women under 50. There’s no data showing it works.”

Medicynical Note: We live in a country that is on the road to bankruptcy caused in great part by profligate health care costs. Controlling these costs is not optional but also is not widely discussed in our bizarre political atmosphere. In the stunted political debate conservatives roar that patients should be able to choose what they want (NO RATIONING, NO DEATH PANELS) but cogently leaves vague who pays when patients choose. Reading between the lines they oppose public funding of medical care, including Medicare and Medicaid. Their solution however, is tantamount to medical rationing by economic status.

On the other side is the notion that all U.S. citizens should have access to a defined level of care. And those who want more can buy additional services (testing and procedures) as they wish.


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