New genetic testing for prostate cancer may reduce unnecessary treatment

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Many studies have found the Prostate-Specific Antigen (PSA) test – the standard exam for prostate cancer – to be a unreliable screening method.   Fortunately, a new report from the New York Times detailed how many more sophisticated prostate cancer tests will soon be on the market.

One such test involves mapping the genome of the cancer itself, in an attempt to distinguish between the most dangerous of tumors and the ones that are slow-growing and do not pose as much of a health risk.  The current PSA test is not very accurate in differentiating between the two, often highlighting tumors that don’t need to be treated.  

The United States Preventive Services Task Force actually recommended against the screening in late 2011, saying more men were harmed through unnecessary biopsies than men who were saved from dying of cancer.

“It’s not that screening doesn’t work; it’s that we haven’t done a great job of targeting treatments for the tumors that need it,” Dr. Matthew R. Cooperberg, an assistant professor of urology at the University of California, San Francisco, told the New York Times.

PSA tests work by measuring the amount of PSA – a protein produced by the prostate gland – in the blood.  The new genetic testing would look for more than just the PSA protein, mapping multiple genes in the prostate, as well as other biological markers.

Two test developers, Genomic Health and Myriad Genetics, have created screening tests that analyze the genes of prostate cancers after biopsy, allowing doctors to gauge just how serious the tumor is.  While the tests may come at a high price – maybe more than $3,000 – the companies say it could potentially reduce spending for unnecessary treatments by nearly $12 million, according to the New York Times.

According to Genomic Health, the company’s test – called the Genomic Prostate Score – will go on sale after Genomic Health releases supporting data on the test at the American Urological Association’s annual meeting in May.  

Myriad Genetics conducted a study on its test, called Prolaris, which was published last year in the British Journal of Cancer.  The research found that 19 percent of men with low-risk scores from the Prolaris test die from prostate cancer within 10 years, as opposed to 75 percent of men with high-risk test scores.

Myriad Genetics’ test has been available since last year, but sales of the product have remained low.  Some doctors are still skeptical that genetic testing is the way to go, because they maintain these tests have yet to be adequately substantiated.  Also, many men who test positive for prostate cancer still wish to receive treatment, even if they are recommended to forgo it based on their low test scores.

However, some experts believe these tests are the step in the right direction.

“Even if we can only convince 15 to 20 percent of men that we have enough confidence that they don’t need to be treated, that will be a big step forward,” Dr. Eric A. Klein of the Cleveland Clinic, who has worked with Genomic Health, told the New York Times.

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Dr. Manny: Yes, some medical tests are unnecessary, but doctors will still do them

The professional societies of 17 medical specialties have recently released a list of 135 medical tests, treatments and procedures they have deemed almost always unnecessary and potentially harmful for patients.  The initiative is part of a campaign called Choosing Wisely and is meant to encourage doctors to either avoid or seriously question performing the tests on the list.

I do agree there are dozens upon dozens of tests that are unnecessary.  After years of being utilized, many of these extraneous procedures have failed to alter the outcome of treatments for conditions that either tend to resolve themselves or can be monitored less expensively.

For many patients, the first question they ask is, “Why were these tests used in the first place?” Well, as these tests were developed, they were implemented in clinical protocols and became the standard medical practices during their times. However, what many patients fail to remember is that science is a living entity.  It is constantly changing and adapting. Unfortunately, it’s also difficult to break old habits, and that’s why today, many physicians continue to use numerous old practices and procedures simply because they have gotten used to them.

One of the problems we currently face is that this type of behavior by the health care system has become extremely expensive, and now the common routine for many doctors is no longer to ‘see patient first, do tests later’ – but instead ‘do tests first, see patient after.’

Now, I have to count myself among the many who has relied on the latter behavior for years.  To me, one of the biggest motivating factors has never been about the money, but instead protecting myself from litigation.  Malpractice lawsuits have prompted many physicians in this country to depend on excessive testing, because they know perfectly well that if they miss a problem, there will be 20 lawyers looking to charge them with negligence. The way these malpractice lawyers operate is by locating paid medical experts – in other words, pitting doctor against doctor – who are more than happy to point out that the reason there was a bad medical outcome was because that doctor failed to do the appropriate test.  

One of the more provocative suggestions from the Choosing Wisely initiative concerns Pap smears.  According to the American College of Obstetricians and Gynecologists (ACOG), doctors should treat women whose cervical cancer Pap tests found dysplasia – unless the abnormalities persist two years later. However, if cervical cancer is present and the gynecologist fails to identify it, I am sure that in less than a minute, a lawyer would find an expert to say this patient should have been treated earlier.  

This is how it goes for many of the ‘unnecessary’ tests listed by the 17 professional societies.  At the end of the day, if we want to change the habits of doctors after so many years, then these academies should be more proactive in protecting physicians against litigation instead of simply making broad statements that leave patients and physicians hanging out to dry.

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