I’ve been thinking for a couple of days now about the recommendations by the U. S. Preventive Services Task Force that we stop testing for the prostate-specific antigen (PSA). The difficulty they point to is not that the PSA doesn’t identify prostate cancers—the fact is that it does sometimes and doesn’t sometimes—but that identifying prostate cancers doesn’t save lives.
This finding, and its twin two years ago, on mammograms, points to many difficulties. Some are medical; some technical; some political. I want to attend in this post to the social difficulties, but let’s start with the political ones. If PSA screening doesn’t save lives, there really isn’t any reason why Medicare should pay for it. Apart, that is, from the demand by Congress that they pay for it.
Here’s the difficulty. Let’s say I am a healthy old man with an enlarged prostate. I need to determine whether I should have tests to determine whether I have prostate cancer. If it didn’t cost anyone anything to perform these tests and to read, evaluate, and disseminate the results and if the tests themselves didn’t pose threats to my health, I would probably say, “Why not?” If I knew I had to pay for the tests, I might say, “Why (should I get the test)?” That is the dilemma faced by the U. S. Preventive Services Task Force, the Obama administration, and anyone else who understands that we cannot continue to spend money on healthcare at the rate we have been spending it.
The Task Force has a really useful view of these matters. The evidence is very compelling at the aggregate level. Here is an account of it from the New York Times. The short way of putting it is that PSA tests, given routinely to men without any symptoms, don’t save lives. And they cost a lot of money. An elevated PSA can lead to a lot of other tests, some painful and some lethal.
The question this article poses is just what we actually get from the routine testing of healthy men. The case is pretty clear at the aggregate level: we don’t get anything—no savings of life—at all. At the individual level, it looks different. Individual patients are a lot more likely to be guided by stories that are passed around at the coffee shop than they are by large-scale longitudinal studies. At the coffee shop, you will hear about the guy whose routine PSA—or digital rectal exam or ultrasound—turned up the existence of a previously unsuspected cancer and that early treatment was successful. You will probably not hear about the 182,000 men in the European test or the 76,000 men in the U. S. test who showed that receiving a PSA test had no beneficial effect at all in saving lives. After that experience, you go to see your internist or your urologist and the question comes up of whether we ought to just “take a peek” at your prostate just to “make sure everything is OK.”
The answer I am exploring today is, “No, let’s don’t just take a peek. If there is a reason to suspect an aggressive cancer, let’s check it out. If there is no reason or if the cancer is the ordinary slow-growing kind, let’s not.” That is the right answer; it is the answer indicated by the recommendations of the task force on the basis of the studies. On what grounds would it be my answer?
How about “citizenship?” Let’s say I love my life and I want to do everything within reason to protect it. Getting routine prostate tests don’t do that. They do something, though. They reassure me that I don’t have prostate cancer. Or they reassure me that the cancer I have—most old men have prostate cancer—is the ordinary slow-growing kind and that “watchful waiting” is the best course of “treatment.” But since I can get all of that—again, absent any symptoms—without any kind of testing at all, another way to say it would be to say that they give me nothing at all. And they cost a lot. I’ve noted some cost statistics below.
Now we get the citizenship part. Is it possible to think of “choosing not to get tested as a way of holding down medical costs” as an act of citizenship? I think so. It isn’t easy, though. Let’s take the analogous case of water usage during a drought. I do all kinds of things at my house to be a “responsible” citizen and to help my city get through this difficult time. That makes a lot of water available in other parts of town where driveway car washings and lawn waterings go up because there is now water available. That just makes you feel stupid and it doesn’t save any water, region-wide, or any money at all.
What you really want to do is to define in this new area—routine prostate testing—what the implications of citizenship are. If the implications are only that expensive and unreasonable medical practices shift from prostate testing to something else, it won’t help. You get the virtuous glow of “doing the right thing” and the aggregate spending on procedures we shouldn’t spend money on continue unabated. It’s virtuous, but it doesn’t do anyone any good.
I’ve been thinking about the analogy of military patrols in Afghanistan. If we knew that routine patrols of an area didn’t increase the security of the area, would we send troops out just to “take a peek,” just “to be sure” that there were no terrorists there? Would it be an act of citizenship for the local commander of U. S. forces there to refuse to send troops out on patrol for no reason? What do we do about the possibility that the area would be secure if we did not patrol it, but patrols would attract insurgents and the security situation would get worse?
This is not an idle comparison, according to the Times article.
From 1986 through 2005, one million men received surgery, radiation therapy or both who would not have been treated without a P.S.A. test, according to the task force. Among them, at least 5,000 died soon after surgery and 10,000 to 70,000 suffered serious complications. Half had persistent blood in their semen, and 200,000 to 300,000 suffered impotence, incontinence or both.
So here’s the final form of the question. Is it reasonable to put the citizen-patient who foregoes routine prostate testing to help make our healthcare spending sustainable in the same category as the citizen-commander who refuses routine patrols to make our military presence sustainable? The citizen-patient will have to live with “not knowing for sure” or with “watchful waiting.” The citizen-commander will have to live with the suspicions of his superiors that he isn’t “sticking it to the _______________ [insert the hate-name of current enemy].”
I admit that the military example is risky because there is a chain of command and decisions about how aggressively to patrol are sometimes—sometimes—made higher up the chain. But I like the similarities. Is it really an act of citizenship to forego what seems like a personal benefit (peace of mind, promotion) in order to follow the larger logic, the benefit being more manageable costs in the healthcare instance and fewer needless casualties in the military instance?
Today, I think it is but I’m just starting to think about what “medical citizenship” might be and I could use some help.
 I thought really hard about whether I wanted to use the word “disseminate” there and decided I could get away with it. Did I?
 I’m not considering here what they do for surgeons who perform prostatectomies or companies who build ultrasound machines. I am not considering the groups of prostate cancer survivors who will go ballistic about these recommendations because it directly attacks the salience of their mission and the basis of their contact with their members. Nor am I considering the boon this will be to Republican candidates who will want to call this approach “rationing healthcare.”