Newt Gingrich on Tuesday night brought “death panels” back to life, arguing that critics had unfairly maligned Sarah Palin (among others) for suggesting the panels were part of the Affordable Care Act. As proof, he cited some medical news from last week: The finding, by the U.S. Preventative Services Task Force, that routine testing of prostate cancer in older men is a bad idea.
Since the federal government will use that recommendation as one basis for determining what benefits all insurers must cover, once the Affordable Care Act is in place, Gingrich said
the most recent U.S. government intervention on whether or not to have prostate testing is basically going to kill people. So, if you ask me, do I want some Washington bureaucrat to create a class action decision which affects every American's last two years of life, not ever. I think it is a disaster. I think, candidly, Governor Palin got attacked unfairly for describing what would, in effect, be death panels.
As you hopefully know by now, the Affordable Care Act will not create the death panels of Palin’s imagination – the ones that sit in judgment over individual patients, ready to pull the plug on grandma because her life is no longer worth saving.
But what about Gingrich's broader implication – i.e., the idea that government decisions about standards for medical care will effectively kill people? That too is misleading, in part because it gives a grossly one-sided view of the debate over prostate cancer screening.
It's a genuinely complicated issue, one that deserves more nuanced treatment -- the kind that Shannon Brownlee and Jeanne Lenzer provided in last Sunday's edition of the New York Times Magazine and that Merrill Goozner offered on his "GoozNews" blog. I have a similar, although not identical, take to theirs.
The background here is pretty simple. Among cancers, prostate cancer is the second-leading cause of death in men. But it is also among the most curable. Surgery remains the most straightforward and (I believe) the most common treatment: Get rid of the gland and you get rid of the tumor. Radiation can work too, on its own or in conjunction with the surgery.
The issue, really, is timing. The Prostate Specific Antigen (PSA) test has made it possible for physicians to detect the cancer much earlier than before, when they relied primarily on digital rectal exams. As with other cancers, early detection improves the odds of getting to a lethal cancer before it kills the patient. That's why physicians began recommending the PSA test for older men starting in the 1990s, when it first became available, and why screening is now more common here than in any other country.
But have American men actually benefitted? Prostate cancer is usually slow developing. In reality, the majority of men will die from something else – heart disease or another cancer, for example – long before the prostate tumor gets them. And the test itself can't pinpoint the lethal cases, for reasons that Richard Albin, the physician who discovered PSA, explained in a Times op-ed last year:
As I’ve been trying to make clear for many years now, P.S.A. testing can’t detect prostate cancer and, more important, it can’t distinguish between the two types of prostate cancer — the one that will kill you and the one that won’t.
Instead, the test simply reveals how much of the prostate antigen a man has in his blood. Infections, over-the-counter drugs like ibuprofen, and benign swelling of the prostate can all elevate a man’s P.S.A. levels, but none of these factors signals cancer. Men with low readings might still harbor dangerous cancers, while those with high readings might be completely healthy.
Meanwhile, the treatments carries their own, very serious hazards. A small number will die from complications. Many, many more will suffer from severe side-effects, including impotence and permanent incontinence. Awareness of those hazards has led many experts to rethink the wisdom of routine prostate cancer screening. And particularly in the past few years, research has given those suspicions a strong statistical foundation. Goozner cites one such study:
According to the Prostate Cancer Intervention Versus Observation Trial (PIVOT), which followed men identified with localized prostate cancer from prostate-specific antigen (PSA) testing for 10 years, with half the group getting radical surgery and half following “watchful waiting,” there was no statistical difference in either all-cause or prostate cancer mortality among the two groups. Fewer than 10 percent of patients in either group died (a surprisingly low percentage given that the average age at the time of randomization was in the late 60s). And while there was a slight, non-significant 3% decrease of mortality in the surgery group, most of that was concentrated in those patients deemed at high risk based on analysis of their tumors and PSA scores.
Maybe the best way to understand this is through an analogy provided by David Newman, a researcher at Mount Sinai Medical School in New York. Brownlee and Lenzer explain it in their article:
Imagine you are one of 100 men in a room,” he says. “Seventeen of you will be diagnosed with prostate cancer, and three are destined to die from it. But nobody knows which ones.” Now imagine there is a man wearing a white coat on the other side of the door. In his hand are 17 pills, one of which will save the life of one of the men with prostate cancer. “You’d probably want to invite him into the room to deliver the pill, wouldn’t you?” Newman says.
Statistics for the effects of P.S.A. testing are often represented this way — only in terms of possible benefit. But Newman says that to completely convey the P.S.A. screening story, you have to extend the metaphor. After handing out the pills, the man in the white coat randomly shoots one of the 17 men dead. Then he shoots 10 more in the groin, leaving them impotent or incontinent.
Newman pauses. “Now would you open that door?” He argues that the only way to measure any screening test or treatment accurately is to examine overall mortality. That means researchers must look not just at the number of deaths from the disease but also at the number of deaths caused by treatment.
... two large studies of P.S.A. screening, published in The New England Journal of Medicine in 2009, came to the same conclusion: There was no difference between the screened and unscreened groups in overall deaths. One trial, conducted in the United States, showed no reduction in prostate-cancer deaths over a period of up to 10 years when men 55 and older were screened. The other, which was carried out in several European countries, showed that screening reduced mortality from prostate cancer by 20 percent, yet the overall number of deaths in each group was the same. Newman gives one possible reason for this: the benefit of early diagnosis could be offset by complications from diagnostic tests and subsequent treatment.
Each study has been criticized for design and execution issues that might have skewed the results, but the failure to reduce overall mortality reported in the European study is probably no fluke, Newman says. An analysis of six studies of screening involving nearly 400,000 men, published last year in the British medical journal BMJ, found no significant difference in overall mortality when screened men were compared with controls. Philipp Dahm, a professor of urology at the University of Florida College of Medicine and lead investigator for the analysis, says the study shows that P.S.A. screening “does not have a clinically important impact” on overall mortality. Or as Kramer, an author of the U.S. study, crisply puts it, “Men may be trading one cause of death for another.”
It was precisely this sort of data that led the Preventative Services Task Force to recommend against routine screening for prostate cancer for healthy men. Still, such skepticism is not universal: Plenty of physicians stand by the testing, in no uncertain terms. It was one such physician that Gingrich quoted on Tuesday evening. And I'm willing to believe many if not most of these physicians come by their positions honestly. That is, they really think the benefits of the test outweigh the risks. (Others, alas, may be ignoring the data -- or thinking about the income widespread screening and treatment generates for parts of the health care industry.)
This controversy raises the same questions that came up about early breast cancer screening and that will continue to come up for many more cancers. And they are intensely personal questions. Do you want to have a test for a cancer that might not be lethal and that might lead you to treatment that could harm or even kill you? Not every patient will answer that question the same way. Not every doctor will either. (This is where I think I'm a bit different from Brownlee, Goozner, and Lenzer -- I'm a bit less wary of possible overtreatment than they are.)
But here we get to the real problem of Gingrich's statement: Nobody wants to interfere with that personal discretion. Even when the Affordable Care Act is fully in place, nobody is going to stop physicians from giving the test. Nobody is going to stop patients from getting the test. Nobody is going to stop insurers from paying for the test.
The only question here is whether the federal government will make prostate cancer screening part of the standard benefits package – that is, one of the services that all insurers must cover, no matter what. And while Gingrich may shudder at the thought of government making these decisions, keep in mind that the alternative is letting insurers make those decisions on their own -- with no transparency, no guarantee of scientific input, and no accountability to democratically elected officials. (By the way, it's not even clear how specific the government guidelines will be.)
Last night, Gingrich was doing what conservatives have been doing throughout the health care debate: Scaring people about something that will never come to pass. And that’s doubly tragic. Not only is he undermining a law that will ultimately save lives. He's also making it more difficult to have a sane, responsible discussion of an issue that desperately needs one.