Evidence-based medicine and PSA testing

A recent article in The Economist has discussed the issue of using evidence to assess appropriate directions in healthcare in the United States. This is an important issue in many other countries including Australia. However in both Australia and the UK there are bodies that have real power to determine which procedures and medications will be funded by central government healthcare programs on the basis of evidence for both clinical- and cost-effectiveness. In the UK the National Institute for Health and Clinical Excellence (NICE) assesses what the National Health Service will pay for. In Australia there is no single organisation like NICE but a number of bodies like the Medical Services Advisory Committee (MSAC), The Pathology Services Table Committee (PSTC) and the Therapeutic Goods Authority (TGA). In the US there is no body with similar powers.

The new Patient-Centred Outcomes Research Institute (PCORI) has been set up in the US by the Obama administration to finance comparative studies of drugs and procedures. However the PCORI is explicitly barred from studying cost-effectiveness and its findings may not be used to deny coverage under Medicare, the federal health program for the elderly. Another older body, the United States Preventive Services Task Force has for some time been reviewing evidence and issuing guidelines on appropriate medical practice. It is this body that has recently generated a storm of controversy by issuing a recommendation that the PSA test not be used for screening for prostate cancer in men of any age.

That recommendation was based on the results from five large, well-run studies. These studies show that PSA screening is of marginal, if any benefit in saving lives and that it results in many men being unnecessarily treated and developing side-effects that affect their quality of life and may even kill them. Leading the outrage at this recommendation is the American Urological Association which represents the urologists who treat prostate cancer surgically. They argue that the major US trial was flawed and that the results cannot be trusted. However a medical oncologist specializing in treatment of prostate cancer writing in Scientific American says that “I essentially agree with the task force’s assessment of the evidence”.

For men considering having their PSA measured, the take-home message from this controversy is that they should discuss the issue with their doctor and inform themselves as best they can before making the decision. You should also read an earlier news article on this site about PSA testing and our prostate cancer and PSA articles.

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