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Screening changes save money [Other Voices]

The show “Breaking Bad” showed the two faces of good and evil and how it affects even the best intended people, e.g. a high school biology teacher, under the correct conditions. It could be one of us.

According to a national business magazine, urologists are the third highest paid practitioners and average just under $400,000 per year. On the other hand, those few urologists who don’t practice aggressive prostate cancer treatment and work with routine or non-invasive therapy but for which the majority of men my age generally have, such as enlarged non-malignant prostate, can only expect to make just over $100,000 per year. A lot of the difference appears to be the extra paperwork and fee limitations Medicare imposes. As someone who took out loans to get an engineering degree, I’m very sympathetic. One urologist was quoted as saying that after more than 14 years of college he wanted to make more than $100,000.

First, one has to accept the reality that we are mere mortals and that there are a number of challenges to our system, and prostate cancer is one of them. About three out of four men my age have something in their prostate that could — but in a very misunderstood way — be labeled as cancerous. But over 99 (and probably more) out of 100 men with my average risk factors will perish from something else.

A large study was done about two years ago by the Preventive Services Task Force, a group of physicians reporting to Congress. These physicians look into the pros and cons of various medical treatments. They looked extensively into medical records worldwide and reported that the consequences of radiation or surgical prostate cancer treatment resulted in about five times as many fatalities as lives saved.

They also estimated a one in three chance of severe injury in the form of incontinence or sexual malfunction.

At that time the American Urological Association, the primary society for developing standards for urologists, was taken aback. The American Urological Society, which has access to the same information, now agrees to change its recommendations and issued a revised standard just over a year ago. The new guide highly discourages PSA screening for men over 70. It uses cautionary advice for testing at all ages. It comes close to stopping PSA screening — but recognizing controversy in changing — allows it after consultation between urologists and patients.

Because of my personal concern and research, I contacted the CEO of my urological practice when the guidelines were changed. He said that, to some extent, they would ignore the AUA guidelines and continue their procedures as before. The revenues generated would more than offset the high malpractice rates.

This change has caused a seismic shift in the urological community, sort of like the pope telling the priests it’s now OK to go ahead and marry. But the window is still open, and from what I can see on urologists’ web pages, the window is expanding.

A single PSA test in one’s mid 50s can give a rough estimate as to whether future PSA screening is necessary. International organizations endorsed this approach. This alone could and should safely eliminate at least half of men, and probably more, from future worry and needless biopsies, as well as needless worry and stress.

No urologist ever recommends this procedure — or even seems to be aware it exists. If one doesn’t have access to medical records and past PSA results, there is now a blood test that will similarly determine this genetic tendency toward early and potentially lethal prostate cancer. This test is now endorsed by the American Urological Society.

I suspect men less than 50 can benefit from PSA screens, and there are still thousands of cases of deaths due to prostate cancer. I would certainly pursue this avenue if I were young again. But nobody is keeping a tally of the 5-1 ratio of those who perish as a result of aggressive treatment versus those saved and the millions of dollars of revenues provided to labs, physicians and oncologists reviewing the biopsies.

Being human, and knowing most physicians generally want to do the right thing, it’s unclear whether many urologists are in denial or just don’t know what to do. They may have second thoughts about the long time to develop a skill set and have a very hard time acknowledging they have to adapt and change what they do. Many urologists are trained surgeons and don’t react well in office settings.

Patients and physicians have to work together somehow. Men are often poor communicators in what they perceive as a touchy area — mortality and sexual functioning come to mind — but we have to be assertive if this situation is to improve. Urologists and their families have to come to terms with a somewhat lower salary for them still probably puts them in the top few percent income-wise.

Dave Pyatt writes from Mount Airy.

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