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Prostate Cancer Screening: From Rationing Treatment to Death Panels

The latest submission from these medieval thinkers is a proposal to defund prostate cancer screening and biochemical surveillance of known disease "for all men over 18, regardless of risk factors."
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Cork, Ireland
Cork, Ireland

Deep in the basement of an obscure but overly powerful government bureaucracy, directives are issued with far reaching implications. The Centers for Medicare & Medicaid Services (CMS), more recognized as simply "Big Brother," arbitrates hundreds of billions of dollars in payments to doctors and, more insidious, what types of treatments are eligible for reimbursement. If you haven't thought it already, let me place the word "rationing" in your frontal lobes.

The latest submission from these medieval thinkers is a proposal to defund prostate cancer screening and biochemical surveillance of known disease "for all men over 18, regardless of risk factors." The directive titled "Non-Recommended PSA-based screening" would financially penalize physicians for ordering this simple blood test.

According to Houston, Texas-based, board-certified, urologist Dr. Robert J. Cornell, "denying PSA screening is both dangerous and irresponsible. This measure directly contradicts practice guidelines established by the American Urological Association (AUA) who dictates best-practice protocols derived from irrefutable clinical data demonstrating both a stage migration toward more favorable disease and an improved cancer-specific survival for those men whose cancer is detected through routine screening." Additionally, as Dr. Cornell identifies, guidance issued by the American College of Physicians, the American Society of Internal Medicine, and the American Cancer Society all discourage this mandate that ignores the life-saving success the urologic community and its patients have enjoyed over the past 25 years.

Prostate cancer has been relegated to a disease with little morbidity and even less mortality. With early detection that relies on the interpretation of PSA screening, the 10-year life expectancy of men diagnosed with prostate cancer approaches 98 percent. This success stems not from the benign nature of the disease, but because of the effectiveness of surgical and radiotherapy treatments and the ability to lay dormant the progression of this cancer with hormonal therapy before it has become locally advanced or metastatic. Dr. Cornell emphasizes, "no man in the U.S., following the strict staging recommendations established by our specialty board, should ever die of prostate cancer. Death from this disease almost always represents a delay in presentation or overt treatment neglect, and such triumph will be egregiously adulterated by this government-mandated PSA restriction".

And for what reason and for whose benefit?

Whether or not a nefarious government plot, the denial of PSA measurement represents nothing short of healthcare rationing for supposed costs savings at the expense of those same individuals who, for decades, paid into a system only to be denied their intended healthcare benefits. If not for rationing, why would CMS financially punish providers for ordering PSA--a measure that can effortlessly be provided from a tube of blood obtained for any other diagnostic reason? The public will rightly wonder what is next on the health care chopping block. If the most sensitive tumor marker for cancer detection is laid to waste, how will our healthcare next be jeopardized? Dr. Cornell concludes, "it will become clear that what is occurring is a deceptive refusal to allocate financial resources to prostate cancer treatment by preventing its diagnosis. Men whose lives would be saved will be denied once available resources by bureaucrats unfit to make such decisions".

Why would CMS deny a simple $25 test when the statistics overwhelmingly proclaim its efficacy? When caught in its early stages, prostate cancer almost seems like no big deal. Five-year survival rates (from 2005-2011) were 98.9 percent! This affliction represents 13.3 percent of all cancers, yet only 4.7 percent of deaths, perhaps another mark of PSA effectiveness.

There is an obvious mathematical calculus to the CMS. With 45 million people or so Medicare eligible, let's assume that half are men and that two-thirds of them receive PSA screening. These 15 million denied tests would, at face value, save Medicare $375 million annually on screening. Presently, it is estimated that there will be 220,800 new prostate cancer cases and 27,450 deaths from this disease in 2015. Prostate is the most prevalent type of non-skin cancer in men and the second only to lung cancer as the leading cause of male cancer death.

How many 2016 cases will go undiagnosed without screening? Will cancer symptoms exert themselves at the locally advanced or metastatic stage, where they are often incurable? How many more men will needlessly perish but for a simple vial of blood? Nearly 60 percent of diagnosed cases are 65 years old and above. Estimates of prostate cancer treatment depend on endless variables, but some cases might cost a couple of hundred thousand dollars over the duration of the sickness even under penurious Medicare reimbursement rates, assuming these conditions will themselves later be funded. At an average of $20,000 per case annually, Medicare currently disburses over $4.5 billion curing this cancer.

So between denial of PSA screening and not treating all new undetected cases, our government saves nearly $5 billion per year. A pretty callous worldview by our taxpayer-funded administrators. At some point, all of the undiagnosed patients become symptomatic. At that point, the disease has become locally advanced or metastatic, and treatment options have become more limited and much more expensive. This morbidity is not only unnecessary but is both "dangerous and irresponsible".

Let's extrapolate. Mr. Jones, 73 years old, received no PSA screening, now has advanced prostate cancer. Medicare declines treatment. He is old, and now disease survival is uncertain at best. What began as rationing has now morphed into a death panel. If that sounds farfetched, five years ago, who would have thought of financially penalizing a doctor for doing a routine, potentially life-saving $25 test for which the provider isn't even compensated? It's the lab companies, the Quest Diagnostics and the Lab Corp's of the world, who collect a small service fee.

It was just three short years ago that Secretary of State John Kerry announced in the Senate chamber, "Prostate cancer is an epidemic- it kills every 16 minutes. This disease killed my dad, but I was lucky to beat it ten years ago. I introduced this resolution (493) in the Senate to bring attention to this silent killer, and the need for additional federal investment in prostate cancer research, education, and awareness". Senate Bill 493 was a bipartisan legislation urging federal agencies to support research for the advancement of diagnostic tools, including novel biomarkers and imaging technologies. Apparently the almighty dollar has triumphed the rarity of a political love-in.

But what of the African American male, who is at a disproportionately greater risk of developing prostate cancer, at a younger age, and in a more aggressive form than he of other races. How will the government justify their neglect of this population of patients who represent 40 percent of prostate cancer deaths, even before the elimination of PSA screening? Black males die a rate 2.3 times that of their white counterparts. Dr. Cornell recognizes, "the Affordable Care Act is predictably resulting in the nationalizing of healthcare and, as such, is willing to ignore standards of patient care by negligently imposing both morbidity and mortality to achieve a financial bottom line."

In a formal comment to the CMS on their proposal, published on November 30 and distributed to their membership, the American Urological Association (AUA) wondered why they were neither notified nor consulted before such a potentially draconian health measure was proposed. Indeed, not a single urologist was invited to represent the physician group that is responsible for treating this disease process and the complications that will certainly arise from its neglect. If I were a conspiracy theorist, I would say something fishy was going on.

Dr. Stuart Wolf of the AUA urges "the USPSTF (an arm of CMS) to seek further input from the urology community as guidance statements are developed. This request is in line with American Medical Association House of Delegates Resolution 225 adopted November 16, 2015, which advocates for the inclusion of relevant specialty societies and their members in guideline and performance measure development, including in technical expert panels" before such restrictions are governmentally imposed.

This is but an early salvo in the trench warfare pitting the medical community against a retrograde army of political hacks. We should all wonder who will next be forced to sacrifice for "the greater good."

Dr. Robert J. Cornell, a board certified urologist, is a graduate of the Columbia University Medical School and completed his urology residency at Baylor College of Medicine in Houston, Texas where he practices today.

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