Screening for various diseases is controversial these days thanks to the U.S. Public Services Task Force and similar agencies in other nations, which have suggested a more cautious approach to screening. These suggestions have been blasted by doctors and patient groups for obvious reasons.
Former Medical Device Daily executive editor Jim Stommen took up prostate cancer screening in a posting at this blog a few weeks back, and while I agree with Jim on a lot of things, I felt one perspective was missing; that of the federal budget.
The problem is that no national economy can support indiscriminate screening for everything that can kill. We might take comfort hearing from the Centers for Medicare & Medicaid Services on Jan. 9 that national health spending grew by only 4% between 2009 and 2010, but lets not kid ourselves into thinking that persistent healthcare inflation of an unusually low 4% per year is sustainable, because the recent norm has been closer to 6-7%. The CMS actuaries acknowledged, by the way, that the lousy economy is the prime factor in the recent lower levels of healthcare inflation. And as the folks at Health Affairs will tell you, healthcare's share of GDP is still at nearly 18%.
It's true that not everyone who contracts breast or prostate cancer is enrolled in Medicare, but government statistics indicate that between 2004 and 2008, the median age at diagnosis of prostate cancer was 67 years. Hence, it's plausible to argue that Medicare and/or Medicaid will pay for a majority of those costs.
One of the problems with screening is that you may spend more than you save, as was argued in the New England Journal of Medicine. I'll also argue that minus a family history or something likewise suggestive of risk, indiscriminate screening runs afoul of the idea of personalized medicine, which I always took to mean that you do everything the patient needs, but you also avoid doing things the patient doesn't need.
Here's something else to consider. In a Jan. 6 article in the online edition of the Journal of the National Cancer Institute, NIH's Philip Prorok, PhD, and others describe a PSA study of more than 77,000 men between 55 and 74, a study that included follow-up of up to 13 years. The authors concluded in the abstract that 13 years of follow-up offered “no evidence of a mortality benefit for organized annual screening ... compared with opportunistic screening,” and that the cumulative mortality rates between the study and control arms were 3.7 and 3.4 deaths per 10,000 person-years, respectively.
Please note that while the numbers did not hit statistical significance, they nonetheless favored the controls, not those on more thorough screening. The authors also said the data indicated no interaction traceable to age, baseline co-morbidity, or pre-trial PSA testing.
I'm reminded of an event I covered at the National Institutes of Health a few years ago after which someone approached me to talk about lung cancer screening. Her position was that an enormous amount of suffering and some cost could be averted by such a program, but my position was then – and still is now – that the bankroll you'd need for something like that simply does not exist.
To be affordable, screening has to be tied to evidence of a meaningful individual risk factor, and is a mortal fiscal hazard as a blind, test-everyone strategy. Willful ignorance of that fact is guaranteed to drive us all into bankruptcy, at which point all that well-intended screening comes to a screeching halt along with everything else.