The Washington Post
October 12, 2011
Forty years ago, my mother-in-law learned from a mammogram at age 57 that she had breast cancer. We immediately sought the best available treatment. She lived for many happy years and enjoyed precious time with her grandchildren. Would she have
died sooner without the mammogram? I don't know. But here's what I do know from four decades of working to accelerate progress against all life-threatening diseases: No screening test is perfect; well-informed patients consulting with their doctors are better equipped than a government agency to make decisions about their health; there are options other than screening everyone or screening no one; and finally, there's no comfort in ignorance.
The U.S. Preventive Services Task Force (USPSTF), a panel supported by a congressional mandate, now recommends that healthy men not receive prostate-specific antigen (PSA) tests, which measure a protein in the blood produced by prostate tissue. I agree that the current PSA test is inexact and, in many cases, leads to overtreatment that can have terrible side effects such as incontinence and impotence. Research supported by the Prostate Cancer Foundation has led to the development of several new molecular markers that could soon complement or even replace the PSA test. These new tests, now in clinical trials pending approval from the Food and Drug Administration, should greatly improve diagnosis and treatment of prostate cancer.
However, in the meantime, the USPSTF recommendation is a disservice to the majority of men. While it would eliminate some short-term health-care costs, long-term costs of treating metastatic disease would be higher. And some men will die. A recent European study showed that testing reduced deaths significantly among men ages 55 to 69. These relatively younger patients are the ones the recent recommendation would most likely exclude from testing because they more often appear to be healthy.
The PSA test doesn't diagnose prostate cancer. But it can raise a red flag calling for a doctor-patient dialogue on medical options, risks, benefits and costs. We need to make better use of it, not ban it, and, as the American Cancer Society recommends, better inform patients of overtreatment risks.
When we founded the Prostate Cancer Foundation nearly two decades ago, more than 40,000 U.S. men died annually from the disease. That toll was expected to rise sharply as population grew and baby boomers aged. Instead, deaths have dropped closer to 34,000. What happened? For one thing, we've supported research that has produced more effective therapies. But also, through media, advocacy events and congressional testimony, we have delivered the message that men should talk to their doctors about a PSA test, and that loved ones should give the same message to the men in their lives.
There's no precise way to know how many lives were saved by increased awareness that led to testing and how many by improved treatment. But experienced urologists tell me that before PSA tests, the vast majority of patients' prostate cancer had already metastasized by diagnosis. Today, only about 20 percent of these diagnosed cancers have spread outside the prostate, partly because PSA tests provide early warning. We shouldn't turn the clock back to the pre-PSA days.
The USPSTF recommendation could produce a cruel form of rationing in which the well-off and well-informed would get PSA tests while many of the poor wouldn't. That could disproportionately affect African Americans, who have higher prostate cancer risk
and death rates.
The argument against testing reflects the same false economy seen throughout America's health system. Spending on care skyrockets while funding for screening, prevention and research drops. Out of each health-related dollar Americans spend, research by the National Institutes of Health represents little more than a penny; and the medical research programs of private industry, universities and governments together total just over a nickel.
Congress should consider research and funding for prevention an investment, not an expense. The Milken Institute estimates that America's gross domestic product will be $5.7 trillion lower by mid-century if we don't contain the containable consequences of chronic diseases. We can save trillions - more than enough to balance the federal budget - by losing weight, exercising, avoiding tobacco, using seat belts and getting regular tests such as PSAs, colonoscopies and mammograms.
The Prostate Cancer Foundation agrees with the American Urological Association that PSA screening provides important information for men and their doctors. In 1993, I was one of those "healthy" men the task force says should not be tested. At least I seemed healthy and felt fine. But I'd recently lost a friend to prostate cancer, so I asked for the test. The result was a reading six times the upper limit of normal. If I'd been kept in the dark by a federal task force, I might not have been here to write this.
Michael Milken is chairman of the Prostate Cancer Foundation and of FasterCures, a Washington-based center of the Milken Institute focused on all serious diseases.