In his early 50s, urologist Hal Scherz received a diagnosis for a disease his profession frequently treats: prostate cancer. The discovery came after several blood tests showed Scherz had rising levels of prostate-specific antigen (PSA), a cancer indicator. In a subsequent biopsy, a single tissue sample-out of 12-came back positive for the disease.
"At that point, there was a decision that needed to be made. Would I watch it and knowingly just continue to have [cancer] in my prostate and not deal with it? Or would I go ahead and get treated for it?" says Scherz, now 57.
After weighing the pros and cons of treatment-it would probably eliminate the chance of cancer spreading, but might result in incontinence and impotence-Scherz opted to have his prostate removed.
"Am I happy that I made that decision?" he reflects. "Absolutely."
Scherz was just one of hundreds of thousands of men who face difficult decisions following screening for prostate cancer. Although PSA testing has been a pillar of preventive medicine since the late 1980s, some new research suggests widespread prostate cancer screening does not reduce overall mortality and results in unnecessary biopsies and surgical procedures. Last October that research led the U.S. Preventive Services Task Force, a government-appointed healthcare panel, to recommend against PSA testing for healthy men.
Many doctors, including urologists and prostate cancer advocacy groups, have reacted strongly to the task force decision, claiming it ignores the individual lives that PSA screening has undoubtedly saved. The criticism is reminiscent of breast cancer screening guidelines from two years ago, when the task force recommended against routine mammograms for women in their 40s. (In defiance, the American Cancer Society continues to recommend the annual mammograms.) With a quasi-governmental body challenging status quo screening practices, some doctors worry the task force has become an agent of a national cost-cutting effort, pushed along by President Obama's healthcare overhaul.
Scherz is one of those doctors. "They have come out with recommendations that are, in my opinion, politically driven," he says, noting there are no urologists or oncologists on the panel. In 2009 Scherz founded Docs 4 Patient Care, a nonpartisan organization based in Atlanta with 4,500 member doctors in several states, committed to educating the public about the implications of Obamacare.
"This is the tip of the iceberg in what I think people can expect to see in the future with a top-down, one-size-fits-all, government-run healthcare bureaucracy," he says. "We are looking at the system, we are looking at the global view of things, instead of the individual."
The U.S. Preventive Services Task Force has existed since 1984, offering screening recommendations for cancer and other diseases based on reviews of the most current research. It consists of 16 unpaid members, experts from various medical fields, who are appointed to four-year terms. Although the task force's recommendations are adopted by doctors and medical groups on a voluntary basis, the Patient Protection and Affordable Care Act gave new clout to the panel's decisions. The law requires that new health insurance plans cover any preventive services the task force recommends, without cost-sharing. Medicare and Medicaid services will also be tailored to task force guidelines.
Many doctors view the panel's role positively. Physician and author Walt Larimore, who practices at Mission Medical Clinic in Colorado Springs, Colo., a church-supported ministry that provides free care for the working poor, said his clinic decided to stop offering PSA testing as a result of the task force decision: "The U.S. Preventive Services Task Force recommendation is-to me-the plumb line upon which you compare the public health messages that are coming out."
Larimore still discusses the facts with his patients. After skin cancer, prostate cancer is the most common cancer among men in the United States, and the second most deadly. Older men, African-Americans, and those with a relative who had prostate cancer are at a higher risk of developing the disease.
Autopsies have shown, though, that a third of middle-aged men-and up to three-quarters of men above 85-had prostate cancer when they died, even if they showed no symptoms. In many cases the cancer is so slow-growing that pursuing treatment options such as radiation therapy or prostate removal offers more risks of side effects, complications, or death than the cancer itself would have posed. Problem is, there's no way of knowing for sure how slow the cancer will grow. For many men, it's a psychological battle wondering whether a simple PSA blood test could result in unnecessary procedures-or save their life.
Even after explaining the pros and cons to patients, Larimore said, "I haven't had a man over 50 choose not to do the testing." He now refers these men to local urologists, who continue to offer PSA testing, following current American Urological Association guidelines.
Larimore's tactful way of letting the patient decide whether to pursue screening is exactly the kind of doctor-patient decision-making some believe is threatened by the governmental task force. Whereas a doctor can assess a patient's entire being and help him or her make the best medical decision based on age, risk factors, and health status, a national screening policy treats everyone as a statistic.
"Governments think of populations, not individual patients," Alieta Eck, president of the Association of American Physicians and Surgeons, told me by email. "Governments deal with global budgets and look at the cost of screening as opposed to the cost of one missed diagnosis. If the one missed diagnosis is my patient, I am the one who is potentially held liable."
Eck said she continues to recommend the PSA test, even though only one out of 1,000 test results may point to advanced prostate cancer-"an arguable waste of money for the 999 but priceless for the one. ... The bottom line is that a PSA costs $88. Let the patient decide."
As the government assumes a larger role in healthcare, Scherz's fear is that those decisions will no longer be in patients' hands. And perhaps not doctors' hands, either.
Although the task force guidelines aren't binding on doctors at this point, Scherz said that Obamacare gives the secretary of Health and Human Services new power to set clinical protocols that doctors must follow. Those who don't cooperate will face financial disincentives, perhaps by being barred from participating in insurance plans in the healthcare exchange-a way of influencing physician behavior with a "big stick."
"We are heading toward a healthcare environment where doctors will no longer be working for the patients," said Scherz. "And patients will have to wonder whether or not the doctor who is taking care of them is really looking out for their best interest, or is making recommendations because they are beholden to some other entity."
Regardless of whether the task force is beholden to cost-cutting, a motive is certainly available: Studies have concluded it costs $5.2 million in screening efforts to prevent just one prostate cancer death, and as many as two-fifths of prostate cancers are treated unnecessarily, since they would never have caused problems over the remaining lifetimes of the men involved.
Larimore, for his part, said he's never seen any evidence the task force was taking costs into consideration, but Scherz isn't convinced: According to some calculations, government health services, including tax rebates, already account for more than 50 percent of U.S. healthcare spending.
"If you're paying for something, you have every right to determine the rules of the road," Scherz said. "That's why you get government making regulations and people all up in arms."