Posted by: notdeaddinosaur | October 28, 2013

Foxes and Guidelines for Guarding Henhouses

I am furious.

For anyone hiding under a rock the last year or so, the latest recommendations about prostate cancer screening have changed from earlier iterations of “screen everyone with a prostate with a PSA (prostate specific antigen, a blood test) and a DRE (digital rectal exam, where the “digital” equipment referred to is a finger) every year” to DON’T DO IT AT ALL.

The United States Preventive Services Task force reviewed the literature and came to the conclusion that routine prostate cancer screening does more harm than good, and should not be done. Hear the emphasis on ROUTINE. In men with a urinary problem suggestive of prostate cancer, certain men with worrisome family histories for the disease and so forth, the above does not apply. We’re talking about blindly screening all comers. And the bottom line is: Don’t.

Screening is to be offered to patients in the context of “shared decision making,” involving a detailed discussion between doctor and patient about the pros and cons of screening (generally PSA testing).

Great. No problem.

Here’s the thing, though: I just had a patient come back from a urological consult for a problem that had nothing to do with the prostate (again) with an order for a PSA. Oh, I said. Did you have a detailed discussion with the urologist about the pros and cons of PSA screening for prostate cancer?


What did the urologist say to you?

Answer: “He said that there were no urologists on the panel that made that recommendation.”


It’s a non sequitur of an ad hominem, perilously close to the barely disguised antisemitism that  discounts evidence of any medical advantages of circumcision.

But it’s the urologist’s hypocrisy that infuriates me the most. If he attributes the negative recommendation to the lack of urological involvement in the guidelines, perhaps he should check out HIS OWN SPECIALTY’S GUIDELINES:

Guideline Statement 1: The Panel recommends against PSA screening in men under age 40 years. [emphasis mine]

Guideline Statement 2: The Panel does not recommend routine screening in men between ages 40 to 54 years at average risk. [emphasis mine]

Guideline Statement 3: For men ages 55 to 69 years the Panel recognizes that the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, the Panel strongly recommends shared decision-making for men age 55 to 69 years that are considering PSA screening, and proceeding based on a man’s values and preferences. [emphasis mine]

Guideline Statement 4: To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening. As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce overdiagnosis and false positives.

Guideline Statement 5: The Panel does not recommend routine PSA screening in men age 70+ years or any man with less than a 10 to 15 year life expectancy. [emphasis mine]

Reading the whole thing is pretty informative. Urologists should try it.

Follow the money: Annual PSAs on everyone from age 40 generate gobs of abnormal results, leading to biopsies galore and of course a plethora of early cancer diagnoses. “We offer watchful waiting,” they say. Ha! Once a patient hears the word “cancer,” they stop listening and start screaming, “Get it out! Get it out!”

See, urologists treat prostate cancer. Find it, cut it out, nuke it; whatever it takes. Never mind that the patient would never have had symptoms from a disease that was never going to kill him. It’s cancer.

But I treat patients; men who end up incontinent and impotent from overzealous treatment by those same urologists who impugn preventive care recommendations because there are no urologists on the panel, but who can’t be bothered to follow their own fundamentally similar specialty guidelines.

Guess what: There are no foxes on the panel developing guidelines for guarding henhouses either.



  1. My Dad is in the same predicament that you describe late in your post. No family history – no symptoms…just a routine PSA that was “a little high.” Upon the requisite investigation, no surprise that cancer cells were present. As you said, “Get it out, get it out!” So they did. And now he wears a diaper. At 62 years old.

  2. To put it another way, if all you have is a hammer, everything looks like a nail

  3. Cancer treatment, all of it, is like swatting a fly on your table with a sledge hammer. You may possibly kill the fly, but your table will never be the same.

  4. Just saw “today” show highlighting how important it is for men to get prostate ca screening complete with an interview with urologist who said “there are no complications of screening”. He suggested matt lauer get rechecked in 6 mo because his prostate was “a little large”

    Why bother with drs, research & multispecialist panels when we have morning “news” tv to educate us. Sigh.

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