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PSA SCREENING??

 

So recently there was a survey that showed 20% of medical treatment and diagnosis testing is really not needed. There were many responses, some I found true, yet others ridiculous…most of the latter I found were from residents or more academic physicians.

Why? Not enough time in the trenches with real patients would be my guess. There was one physician (I’ll refer to as “Dr B”)

Who’s response was along the lines of…”these are real people not a number in a textbook….and further when a study says for example 5-10% mortality if you miss this diagnosis it’s not a number in a book it’s a real person sitting in front of you”….I should have just said….”yes!! Exactly!!!”

Except of course I wrote a long long longwinded response, which I turned into this months blog…..

 

Dr B’s comment really is the only one that hits the proverbial nail on the head. I’ll give you an example. One thing I tell my urologic patients is …

“Many times what is appropriate in a textbook of ivory tower medicine …just doesn’t work In the community in the real world”

PSA testing and prostate biopsies for example. There is a US study that shows no survival

Advantage with PSA screening and prostate cancer treatment. Hmmmm….ok but I just don’t see that in clinical practice. In fact, I did not see that thinking pan out in the early 1990’s when this was attempted. Nor have I seen this pan out the last few years when it’s been tried again. What I saw in the early 1990’s and again recently is patients that were probably curable at time of diagnosis become not curable when treatment was instituted, and more patients coming in with locally advanced or metastatic disease at the time of diagnosis. Nor do I see the sequele of locally progressive prostate cancer bleeding and in clot retention in the hospital….nor many patients with the horrible sequele of metastatic bone disease….and the same study in Europe shows a 29% survival advantage…that goes along with what I see in clinical practice. What I’ve found over many years of practice is that if there is a study that has good results for a procedure a test or a drug….and you just do not see that in your practice whatsoever….99% chance when you go to the national meeting and speak to colleagues , they will be having the same problem and within a year or two that practice is well out of vogue.

But…back to prostate cancer

Remember….like Dr B wisely stated above….real people not a textbook….patients come in and their PSA is high and there is no other reason and they know they have a 30-35% chance of prostate cancer because they already referred to Dr Google…and I were to say…oh don’t worry about it…there are gov studies that show we urologists over-biopsy and if we only biopsy “when “X” occurs”

And that way I only miss 13% of the cancers”….and see that way I make sure I don’t over utilize and over biopsy and save Medicare x amount of dollars”…..

What do you think their response is?….trust me it’s not “thank you for not performing a test and I’ll rest assured there’s only a 13% chance you missed my cancer”

It’s…I paid into Medicare my whole life…and they go to someone that will do the biopsy and find out. And when their biopsy comes back negative…its overwhelming relief and thanks and praise for giving them that peace of mind.

I’ll never forget being at a conference and one of the ivory tower academics from CMS was giving this lecture and his conclusion was we would eliminate “X” amount of biopsies by utilizing this particular criteria

And only miss 13% of cancers.

So I asked ….what if you’re one of the 13% ? His answer made me realize that people that physicians that practice in the trenches of the community everyday should be at the very least asked about policy….his answer was “if your patient is one of the 13% then he has his God given right to sue”. Thank you for that, sir, I can rest assure you have my patients and my best interest at heart. That was an attempt at sarcasm.

When I hear “Doctors over utilize”…I’m sure there are some. I just don’t know any personally. More often, however, the person making the over utilization comments usually does not take care of real patients or is looking at a piece of paper with statistical analysis. The true human factor is basically not taken into consideration, nor the absolute fact that medicine is not a black and white exact science. Let’s look at PSA testing. PSA has a high “sensitivity” for prostate cancer, not necessarily a high “specificity”.

What does that mean? It’s not a perfect test….but it’s the best we have today. There are many different criteria and new tests etc but none of them are as accurate.

Plain, simple, common sense terms….you can have a high PSA that is not secondary to prostate cancer. That being said you’re gonna see some negative biopsies.

But….that’s the best we have right now today in 2017…same in 1992 or whenever the last time I heard PSA was not necessary. Furthermore Unnecessary treatment?? We can just watch this cancer!!!!. Sometimes, yes you can. However, an extremely large percentage of the time the biopsy results underestimate the amount and aggressiveness of the cancer when the entire prostate is removed and pathologically reviewed. So, I’m sorry but I do not know any urologists that sit in their office and dream about doing more unnecessary prostate biopsies. Let’s see at cost plus 2% that Medicare reimburses me….if I did an extra 8,357,000 unnecessary prostate biopsies..wait after taxes and office expenses….and factor in for inflation …ok 32,974,000 unnecessary biopsies I can get a new Toyota Tundra!!!!….I’m obviously being sarcastic, however; the thought that physicians actively do unnecessary procedures and biopsies etc in reality is for the most part ridiculous. I think it is imperative to use medical studies along with your own clinical experience and always do what is best for your patient in their particular situation. That’s the best we can hope for with a science that is not exact.

I had this trainer in residency that had cancer and beat it (Dr R)…as have I for that matter(Dr S)and he said something one day that I never heard from CMS or a statistician or anyone else for that matter. That being said, his statement was so practical and human…you cannot factor it in to a statistical analysis or cost analysis. This goes right along with “Dr B’s point above as well”…

“When youre the patient…when is cancer insignificant?”

That…in itself is such a powerful and true statement….enough said .

 

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Frank L. Simoncini, DO, FACOS

Southeast Valley Urology

1501 N Gilbert Rd #204

Gilbert Az 85234

480-924-7333

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