on subsidies

From the curios of immaculate conception to the perversities of public health in Ontario…

The day I arrived in slippery gray (but so succexy) Toronto, the province announced a $150-million dollar package intended to cover all screening tests for men, the media brouhaha resting on prostate cancer screening in particular. It used to be that unless you were a high-risk candidate, a PSA-level blood test cost you roughly $30 out-of-pocket; under the new scheme it will be OHIP-covered, always. As luck would have it, I was actually in town for a conference about screening. For the first time in my new position, I was attending sessions dominated by well-groomed men in suits, orated by overconfident American experts, and consensus-bound by the most unlikely sentiment: criticism of the screen-happy status quo.

Needless to say there wasn’t a single urologist sitting cabaret-style among us. And it wasn’t open to special interest groups or industry reps.

Here is the deal with prostate screening: First off, that digital rectal exam that gets the butt end (ergh) of about half of all men’s health joking out there is, actually, almost useless in the detection of PC. There are other uses for DRE, but as prostate cancer detection it has low specificity and low sensitivity- so lots of men who have it are told they don’t, and lots who don’t are told they do. The PSA is better at finding what it intends to find, but then there is the often-neglected question with screening: what are you going to do with what you find? Screening is not done for the sake of screening, but to lead to interventions and, hopefully, reduced morbidity and mortality.

Mortality from prostate cancer has stuck at 3% since they started tracking, while incidence trends have mimicked the popularity of the PSA test….rising when there are encouraging population health measures like the Ontario announcement last week, and falling when the debunking message reaches a receptive clinical or policy audience. In short, detection has done nothing to improve mortality. When PC is detected, men can “watch and wait”, or have surgery. One percent of patients die in these surgeries. Morbidity is high and horrific: at least 30% of patients end up with incontinence (urinary and/or rectal…ew), and another third with impotency. Since PC has such a long lead time, these men may be very young when they go under the knife, and have to live with the dual devils of incontinence and impotence for a very, very long time. Which arguably would be okay if the sacrifice was saving their lives, but it isn’t. Mortality simply has not changed.

About 30-40% of men are found to have prostate cancer when they die. In the vast majority of cases, the PC didn’t kill them. Any number of other diseases, infections or injuries did.

It is not harmless generousity to push PSA testing by way of economic incentives like McGuinty’s subsidies. As far as I can tell this financing package is yet another distraction from the failure of the cancer industry (including public-administered health care provision) to do much of anything to reduce cancer mortality since the disease blimped out of social hiding some decades ago. While I gather many physicians have seen the evidence of the bigger trials (PLCO and ERSPC), PC remains misunderstood by most men and frankly most policymakers. Clinicians continue to offer it because patients ask because they hear the hype, hype that comes from groups that respond perversely to the risks of testing by promoting its availability. This phenomenon is apparently called the “popularity paradox”. The campaigning is the loudest for tests that are the most likely to cause harm…as if the patient groups behind these campaigns are responding with evangelism to their cured existence, even if campaign masters’ own cancers were not discovered through screening.

I asked Dr. Gilbert Welch, who wrote the controversial “Should I Get Tested for Cancer?” if somewhere in his book I’d find an economic analysis. He scoffed. Even if population screening wasn’t extremely costly and wasn’t eating up time in pathology labs and primary care visits, it would be harmful because it leads to physical harm. Men get hurt by these unnecessary surgeries. To Welch, an economic analysis was irrelevant, because there would be absolutely nothing to file in the benefits side of an equation, and the harms are overwhelming.

So, what can a man do in the face of one of the top three cancers among men? Pay attention to his body and talk to a physician when something changes. Some would argue that incredibly detailed discussions of all the risks of PSA testing and seeking informed consent is the way to go; I am cynically proposing “informed decision-making” is not economically or ethically worth the time: if it’s a bad test, don’t offer it, period. PC is one of those cancers that is either never going to progress to causing symptoms, let alone death; or be curable once symptoms arrive; or be incurable no matter when you detect it (including through presymptomatic screening programs). Only very very rarely will presymptomatic diagnosis be necessary for cure…certainly not often enough to justify the harms of general screening.

I realize this post isn’t terribly Alice B. But then my Alice would be incredibly cranky if her man had unnecessary physiological impotence for the last thirty years of his life.