The Real World Implications of Screening Policies

The Real World Implications of Screening Policies

David L. Graham, MD, FASCO

May 06, 2012
Note—All the information below has been publicly reported by the principals involved and this comment involves no HIPAA violations.

An 81-year-old male had a screening PSA performed and was subsequently found to have prostate cancer. The Gleason score was not reported but the patient elected to undergo external beam radiotherapy and publicly stated that he was told he had a 99% chance of cure.

The day his diagnosis was announced his company lost nearly two billion dollars in market valuation.

It doesn’t take much to figure out that the patient is Warren Buffet.

All this occurred because an 81-year-old man was screened for a disease he had upwards of a 40% chance of having by previous autopsy studies. To put it another way, 40 out of every 100 men his age who pass away have the disease and never knew it.

Many of the discussions regarding the benefits or problems of PSA screening talk about how many men we are over-treating for this disease and the effects of therapy they did not need to incur. Some efforts have been made to quantify the economic impact of this over-treatment.

Would Mr. Buffett be a candidate for active surveillance? Without more information regarding the disease, it is impossible to say. Would Mr. Buffett have lived out the rest of his natural days without knowing this diagnosis if not for the PSA test? Again, it is difficult to say, but taking him at his word, a quoted 99% chance of cure would suggest a pretty favorable pathologic profile. What we do know, however, is the direct economic impact of his diagnosis.

I am not suggesting we get rid of PSA for screening. I do believe it has a very important role in patient care. There does, however, need to be an adjunct to the diagnoses that occur as a result of PSA screening to help us determine those men who need to be treated as opposed to just monitored closely. There also has to be an honest societal discussion, based on knowledge and science, about an appropriate time for screening to cease.

We are not likely to get many examples as dramatic as this, but shouldn’t this one case—a direct two billion dollar impact from one person’s diagnosis—serve to spur some discussion?


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