The Prostate Mistake



This is a great op-ed by Richard Ablin, discoverer of the prostate-specific antigen test, about the misuse to which his discovery has been put:

In approving the procedure, the Food and Drug Administration relied heavily on a study that showed testing could detect 3.8 percent of prostate cancers, which was a better rate than the standard method, a digital rectal exam.

Still, 3.8 percent is a small number. Nevertheless, especially in the early days of screening, men with a reading over four nanograms per milliliter were sent for painful prostate biopsies. If the biopsy showed any signs of cancer, the patient was almost always pushed into surgery, intensive radiation or other damaging treatments.

The medical community is slowly turning against P.S.A. screening. Last year, The New England Journal of Medicine published results from the two largest studies of the screening procedure, one in Europe and one in the United States. The results from the American study show that over a period of 7 to 10 years, screening did not reduce the death rate in men 55 and over.

The European study showed a small decline in death rates, but also found that 48 men would need to be treated to save one life. That’s 47 men who, in all likelihood, can no longer function sexually or stay out of the bathroom for long.

A kind of odd piece of conventional wisdom has hardened that it’s dishonest of Barack Obama or Matt Yglesias or anyone else to suggest that there are some free lunches to be had in the realm of health reform. I think it’s clear that you can’t do public policy on a major issue entirely with free lunches, but realistically the policy realm is full of low-hanging fruit and free lunches. The only reason to think it wouldn’t be would be an odd assumption that we reached near-optimal policy on all topics sometime around 2007.

In the health care domain, in particular, a mix of weak science, bad economic incentives, and poor mathematical understanding leads to a fair amount of over-treatment. And over-treatment for cancer isn’t just an issue of spending money that didn’t need to be spent—treatment for prostate cancer normally has very unpleasant side effects and it’s really cruel to inflict it on men who don’t actually need the treatment. And as far as cancers go, that’s totally typical. Reducing over-screening and over-treatment would probably save money (though it’s always hard to know what the long-term impact will be since everyone eventually gets sick and dies) and will definitely spare patients a lot of pain and suffering.

Or consider our lack of research into the comparative effectiveness of different pharmaceuticals, which is basically a five dollar bill sitting on the sidewalk.