Tuesday, June 30, 2009

Obama's Health Policy and Prostate Cancer

This is what you could hear if it's passed.....

You’re Too Old!

By J.P. Morgan, D.Min.
Author of: Faith and Proton Therapy vs. Prostate Cancer
ISBN: 978-1-934666-29-6

The U.S. Preventive Services Task Force (USPSTF) says that if you are 75 years or older, you are too old to have prostate cancer screening. In the August 5, 2008 Issue of Annals of Internal Medicine (Vol. 149 – Number 3), they recommend that doctors do not screen such patients or those who have a life expectancy of 10 years or fewer (the time required to experience “a mortality benefit”). Their technical reason has three parts. They start with the conclusion that the psychological impact of false-positive test results could be harmful. Next, the elevated prostate-specific antigen (PSA) screening tests could lead to the discomfort of a prostate biopsy, which in turn could lead to treatments that could cause more harm than good. That’s their position, evidently based on the general health, and life expectancy of those 75 and older, since, according to USPSTF, there are “competing causes of death” for this age group. Not even testing them could amount to a head start for prostate cancer in the competition.

The Task Force, first convened by the U.S. Public Health Service in 1984, and since 1998 sponsored by the Agency for Healthcare Research and Quality (AHRQ), has no enforcement powers. However, some of its recommendations could be used to identify “unnecessary” tests and screenings mentioned in proposed healthcare legislation since they are alleged to cost billions of dollars

As a 76-year-old recent prostate cancer survivor (for now), who continues to receive good reports (PSA reading of 1.6) eighteen months after proton therapy, I can’t agree with them. Although they claim statistical data to overwhelm my anecdotal evidence; in this era of equality, shouldn’t everyone have an equal opportunity to use available medical resources? Or, is this perhaps another, not so subtle example of the allocation of such resources? Has “someone” concluded it is a waste of Medicare money not only to treat those over 75 with prostate cancer, but also to even bother testing them to see if they have it? Are we fast approaching a time when cost and a triage criterion of “likely to benefit from the procedure,” will be used as an excuse to ignore any medical needs of the elderly as our country ushers in an era of euthanasia type mentality? At a press conference on June 24, 2009, President Obama signaled that this is the road his administration wants to travel when commenting on a 100 year old women who had received a pace maker. He indicated that she should have just been given a pain pill.

There have been ongoing discussions in the medical community concerning proton therapy treatments for people of any age, because of the cost. The Blue Cross Blue Shield (BCBS) parent organization (HCSC) for four states, on May 22, 2009, withdrew an earlier announcement that they would no longer cover Proton Therapy because of its cost. (An organized letter writing campaign by those of us who had such treatments helped change their mind.) Medicare was also considering such a move, but they too have pulled back from such a decision –– for now.

Because of my firsthand experience, this article highlights one form of cancer, a particular modality, and its cost. It would seem logical, however, that testing and treatment costs, along with the patient’s age, will be considered during any governmental decision-making process to determine how and who to treat in a national health system. The USPSTF already has recommendations available on many medical procedures which could be used to deny future funding. It is interesting to note that age is one of the factors they consider in evaluating a service. (Task Force reports can be reviewed at: www.ahrq.gov/CLINIC/uspstfix.)

Regarding prostate cancer protocol, I do understand that this type of cancer can be slow moving, and yes, my urologist gave me the option of doing nothing (except “watchful waiting”) after my biopsy revealed two cancerous cells. He asked me “Do you feel you are going to live more than five years?” My affirmative answer triggered my review of treatment alternatives. If I would not have had my yearly PSA test, there would have been no biopsy, and no need to look for treatments. That is what USPSTF is suggesting would have been best for me. Even though I am in an increased risk category, that includes older men, African-American men, and men like me, with a family history of prostate cancer (my father and his father both died from it). Who would be liable for not allowing me the opportunity to monitor the condition of my prostate and take precautionary action? What if the cancer spread and it became too late to do anything about it? Since somewhere between thirty and forty thousand men die from prostate cancer each year, there must be some danger associated with ignoring the possibility completely (which is different from watchful waiting). I guess that is all right statistically speaking, since the USPSTF report tells us that the medium age of death from prostate cancer in the U.S. from 2000 through 2004 was 80 years. For me, living with cancer in my body at any age wasn’t acceptable.

Although it is a mute point in view of my overall challenge to the Task Force’s Class “D” (the strongest) recommendation, I have to take exception to their position on PSA scores and, as a retired university professor, I feel compelled to address some of their research methodology. I also reject the “mortality benefit” argument , but on moral grounds.

The Task Force mentions that the conventional PSA screening cut-point is a “4”. Several medical professionals in the field of prostate cancer have told me that a better predictor of active cancer cells is an increase of .75 between any two tests (PSA Velocity). The velocity issue would seem to call for regular testing. I had hovered above “4” for several years and never had to have a biopsy. When I hit 5.6, I was retested to make sure it wasn’t a false positive. The second time I reached double figures (11.53) which triggered a biopsy, and eventually the search for a treatment. There was a patient receiving his radiation at the same time and location as me who had a PSA of 1.9 (it had jumped from a 1). His biopsy found several very active cancer cells.

When speaking about screening, I would have thought USPSTF would have at least mentioned that Johns Hopkins is developing what is known as EPCA-1 and EPCA-2 as a potential replacement for the current PSA tests. The object is to reduce the number of false-positives which the Task Force feels produces adverse psychological effects.

The report mentions the pain and discomfort associated with a prostate biopsy. That is nothing when compared to the possibility that the random placement of the needles during such a biopsy could miss the cancer. Moreover, when a cancer cell is detected, “needle tracking” has the potential of spreading it. The Diagnostic Center for Disease in Sarasota, Florida, address this subject in a Press Release dated February 19, 2008. They also call for improving pre biopsy diagnostic skills through imaging such as their MRI-S scan as an alternative to a “blind” biopsy.

Since the USPSTF report found “convincing evidence that treatment for prostate cancer detected by screening causes moderate-to-substantial harms, such as erectile dysfunction, urinary incontinence, bowel dysfunction, and death,” I searched the report for what type of treatment they were talking about. It appears that they arrived at their conclusion based on the oldest treatment –– radical prostatectomy. In an e-mail response to my comments on the evidence synthesis, Doctor Lin, the lead author of the report, stated they did look at other treatments, but did not address them because “there{are}no published randomized controlled trials of either.” (Either includes the “PSA velocity” issue I raised.)

So, we are left to wonder if the conclusion of the U.S. Prevention Services Task Force concerning the potential negative outcome of treating prostate cancer would have been the same had the patients received da Vinci prostatectomy? What might have happened had they used radiation therapy via Brachytherapy (radioactive seeds), or external beam radiation such as Intensity Modulation Radiation Therapy (IMRT), some using guidance imagery; or the target specific Proton Therapy? Each of these procedures claims to reduce the harmful side effects associated with surgery. I chose the University of Florida Proton Therapy Institute because its program and people convinced me they had the ability to reduce or eliminate such effects. At least for me, the Institute delivered what I expected.

None of this matters if you are 75 (for now) or older and doctors follow the recommendations of USPSTF. You will never have to make any treatment decisions because you will never be tested for prostate cancer. You will have as much control over prostate cancer’s threat to your life as an unborn child has when he or she is about to be aborted.

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