The Case of Unethical Screening Tests

Believe it or not, doctors are still doing screening tests that are unethical because they don’t actually screen effectively for diseases but are still done because there’s money in doing the test. One test that continually comes up when it comes to ethics in medicine is the PSA test or prostate specific antigen. According to a recent New York Times report on the test, the PSA was considered inappropriate for screening because it is inaccurate much of the time and doesn’t necessarily tell you anything.

Interestingly, the New York Times article was written by Professor Richard J Ablin, the professor who first discovered the prostate specific antigen in 1970. According to his article, about 30 million men currently get screened for prostate cancer using the PSA test and it has become the most commonly used test for prostate cancer screening since 1994.

The problem with the test is that not all prostate cancer will reveal an elevated PSA and people do the blood test and skip the digital rectal examination, which was the previously most common test for prostate cancer. According the Professor Ablin, the popularity of the PSA test has become a costly public health issue—a disaster, in fact.

Medicare, the Veteran’s Administration and some health insurance companies have spent about $3 billion per year on the prostate screening antigen test. And the test, according to Professor Ablin, is not much more than a coin toss when it comes to accuracy. A good test for prostate cancer would differentiate between prostate cancer that can lead to death and prostate cancer that is relatively benign and, to date, no such test exists.

The PSA test tells a man how much prostate specific antigen he has in his bloodstream. Certain other things, like infections, benign prostatic hypertrophy and taking certain over the counter medications can artificially raise the PSA so that cancer will be suspected where it doesn’t exist. Low PSA readings mean nothing because prostate cancer can still be there. If a man has a high reading, he will be subjected to further expensive tests, such as a biopsy of his prostate or a prostatic ultrasound that many not show anything.

The continued use of the prostate specific antigen test is, according to Ablin, because of drug company advertising and advocacy groups that push the test as a valid screening test for prostate cancer. The American Urological Association is still recommending the test as is the National Cancer Institute, although they are vague on the matter.

The use of PSA testing isn’t completely a wash, however. For example, if a man has a known prostate cancer, a PSA test can be done to see if it is elevated. After treatment for prostate cancer, the PSA test is followed. If it rises unexpectedly after treatment, it means the prostate cancer is growing or has come back.

Instead the test is used on the population of men over the age of 50. All of them. Ablin suggests that this profit-making practice be stopped. Can this be done? How does the individual patients feel about this?