Just 10 days after my post on Crikey expressing concern about the lack of information I received from urologists about the probabilities of various outcomes, following a raised PSA level for testing for prostatic cancer, lo and behold I have said information! It is good news for me, but not such good news for many urologists.
The New York Times reported on 19 March on two large studies — “the first based on rigorous randomized trials” — published on the PSA test.
In summarising the results the NYT quotes Dr Peter B Bach, a physician and epidemiologist at Memorial Sloan-Kettering Cancer Center:
… one way to think of the data is to suppose he has a PSA test today. It leads to a biopsy that reveals he has prostate cancer and he is treated for it. There is a one in 50 chance that in 2019 or later he will be spared death from a cancer that would otherwise have killed him. And there is a 49 in 50 chance that he will have been treated unnecessarily for a cancer that was never a threat to his life.
Hmm … now I know these odds, in future I will not have any PSA tests done — even before I factor in the incontinence and impotence that treatment might bring.
But reverting to my more professional role as a health economist, why have all these tests been being carried out and at great financial cost to the taxpayer and the private insurance holder? And what about all the anxiety they have caused?
I have never been a big fan of fee for service medicine. Doctors are human and if we pay them according to piecework, of course they will do more pieces. Who wouldn’t? But it is a bit much when they do things that are not evidence based, that can make patients anxious and for which patients struggle to get relevant information on which to make informed choices. Part of the answer is to look very closely at the heavy reliance our health care system has on FFS medicine. If doctors were paid by capitation (ie by the number of people they serve) or by salaries would there be so many PSA tests?
Will we see the end of the epidemic of PSA testing? Will we see a decline in the dominance of FFS medicine? Will clinical trials and trials of screening tests in particular please take more account of unnecessary anxiety for patients!