Monday, September 20, 2004

PSA. HRT. SSRIs. Houston, we have a problem.

Professor Stamey first suggested that a blood test for prostate-specific antigen (PSA) could indicate the presence of cancer in a paper in The New England Journal of Medicine in 1987. The discovery spawned a vast prostate screening industry - nearly a quarter of a million men will be diagnosed with prostate cancer in the US this year - and a huge growth in the number of men treated for the condition. Now, he has recanted, and suggests that the test merely indicates the size of the prostate and may do more harm than good by encouraging over-treatment. Many of the cancers detected by it are too small to be clinically meaningful and many men may have been unnecessarily treated. 'The PSA era is over,' he said in The Journal of Urology.

Ten years ago, when I was actively practicing medicine, I was among those on the front line who were very unsure about the value of the PSA test. I give full credit to my internist colleagues for their deep and abiding suspicion of the PSA. Then Dear Abby/Ann began pushing it, then Bob Dole, then resistance became futile.

Now it looks bad for the PSA.

Hormone Replacement Therapy had a similar path. SSRIs are looking shaky -- primarily because an emergent (unconscious?) de facto collusion between manufacturers, researchers, academics and publishers produced a biased publication base. (One UK researcher clinician emerges as a hero in the SSRI debacle -- a lesson about the need to resuscitate the dying breed of clinician-researcher.)

Medicine has a problem. I think it's a research funding, tenure, promotion and publication problem, compounded by issues with professional identity and severe stress and distress among primary care physicians. The situation isn't quite hopeless; some of the steps being taken with electronic publication (advertising free!) and clinical trials registrations are very important. I think we need the AHRQ to be fully alive again -- it was badly wounded about 10 years ago by an unfortunate alliance between libertarian ideologues, anti-science politicians and fearful subspecialists. Maybe orthopods could do penance by resuscitating the AHRQ.

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