As I’m fond of telling most of my patients, wading into politics in the exam room or online typically only gets me into trouble, so I’ll try to stick to the medical facts here. You’re probably already familiar with the fact that former president Joe Biden was recently diagnosed with an aggressive form of prostate cancer that has spread to his bones. Biden, who is 82, reportedly began to experience urinary symptoms that led him to seek further care. During this consultation, a nodule on the prostate was discovered, and subsequent investigation proved it was indeed cancerous.
As many already know, there is a screening blood test for prostate cancer called a PSA which is routinely used to monitor for changes that might indicate a problem with the prostate. What many seem to NOT be aware of, however, are the recommendations for use of this screening test. The United States Preventative Services Task Force, or USPSTF, recommends prostate cancer screening with a PSA be selectively offered to male patients aged 55-69, and recommends against routine screening in patients over the age of 70. For patients in the 55-69 age range, the recommendation is listed as “Grade C” – indicating a “moderate” likelihood that the “net benefit is small”, and for patients over 70 the recommendation is listed as “Grade D” – indicating a “moderate or high certainty that the service has no net benefit, or that the harms outweigh the benefit.”
Confused yet? Let’s throw another wrench into the equation. The American Urological Association and American Cancer Society both offer their own, different spin on when to screen for prostate cancer, emphasizing the importance of “shared decision making,” and “talking with your doctor” about when to start or stop screening. But how often does this conversation happen? As it turns out, not very – maybe as many as 2/3 of eligible men never have the conversation various national guidelines are suggesting.
The outrage over Biden’s late diagnosis and the low uptake of screening conversations suggest that these recommendations are almost completely out of step with the reality of primary care in the modern era. As a practicing primary care physician myself, I understand – it’s a fanciful notion to suggest that most primary care practices can devote the appropriate time in a 15 minute visit to discussing the risks and benefits of prostate cancer screening. The reality is that there is simply not enough time to accomplish this goal during the office visit, which is the only way the doctor is reimbursed for their work in a traditional insurance-based setting. The vast majority of physicians are either going to just order or not order the test on everyone, and hope for the best. But really what I’m getting at here is that guidelines recommending “shared decision making” in primary care are likely to remain an academic exercise in a predominantly fee-for-service primary care system which is poorly funded, too rushed, and largely unable to meet the demands that society places on it.
While well-meaning, every recommendation toward “shared decision making” in primary care will ultimately fall flat unless primary care becomes appropriately funded, accessible, and given the prominence of place it deserves in the medical pantheon. A recommendation for “shared decision making” requires there is appropriate time for a decision to be discussed and made in the first place, which is simply a fantasy in a traditional primary care environment. There are certainly some positive developments in this regard with the adoption of alternative payment models and the rise of the direct primary care movement (which is why I currently practice in this setting), but one wonders whether any of the members of the recommendations committees have visited their PCP recently to inquire about prostate cancer screening. If they did, one wonders how much time they devoted to having this conversation to the extent they themselves recommend.