The Screen You Skip Is Cheaper Than The One You Will Need

In 2012 the US Preventive Services Task Force gave PSA screening a D grade. Not handle with caution. A D: do not do it. For most of the decade that followed, the share of men screened fell, and the prostate cancers that were found were found later and worse. The panel had priced the harm it could see, which was over-treatment and unnecessary biopsies. It had no line item for the man who never got a baseline. That is what screening actually is. An actuarial decision, not a courage test. Three variables: the probability, the cost of the test, and what you are willing to do with the answer. Everything else is mood. The probability that a screen finds something you would rather not know is not zero. The probability that you are currently pricing it at zero is close to one.

Peter Attia is more aggressive here than the guideline and says so. The USPSTF starts colorectal screening at 45. He starts at 40, and in selected cases 35. He reads the 45 to 50 line as a population compromise built around cost and access rather than biology. Show up at 50 with no prior scope and you are not early. You are overdue. Frequency follows the findings. Clean, every ten years. Polyps, every three to five. It is the only test in the set that removes what it finds while it is still a polyp, and a polyp taken at four millimetres is a procedure. The same lesion at four years is a diagnosis. I did sixteen years of field work in rural Nigeria, post-conflict Serbia, Kazan and Fukushima. I have a 2013 Cyprus bail-in on my record. What I did not have, at fifty, was a scope.

Attia wants a baseline PSA at 40 to 45, taken before there is anything to interpret, so that there is a line to read later. One absolute number is a position. Velocity is the direction. Density, PSA divided by prostate volume on MRI, is the concentration. A rising velocity on a small gland is a different animal from a stable number on a large one. If the PSA is elevated the next step is multiparametric MRI, not a blind needle. Free PSA percentage, 4Kscore and the Prostate Health Index exist for one purpose: to reduce the number of men biopsied for nothing. The 2012 recommendation rested on an assumption that finding something does more harm than missing it. For a fifty-year-old with a family history, that assumption was never true. You do not manage a business off one quarter. Why manage this off one number.

The profile Attia was asked about: a fifty-year-old man whose mother had breast cancer and an aneurysm, with diabetes on both sides of the family. Under the narrow NCCN criteria, most of that history does not qualify for genetic testing. He tests anyway, because the test costs a few hundred and the result rewrites the surveillance schedule for the next thirty years. The panel is broad: BRCA1, BRCA2, PALB2, CHEK2, ATM, TP53, and the Lynch syndrome genes. BRCA2 is the one that bites. It raises the risk of aggressive prostate cancer by roughly two to five times, which moves both the age screening starts and how hard it is run. It also opens male breast cancer surveillance, and pancreatic surveillance nobody would otherwise order. What a hereditary panel does not do is explain what already happened. It tells you where surveillance goes next, and how often, which is exactly what you had been guessing at.

Screening is not a courage test. It is an actuarial decision with three variables: the probability, the cost, and what you will do with the answer.

Whole-body MRI is his signature position and the most contested. He scans himself annually. No ionizing radiation, enough soft tissue resolution to find disease while it is still small, and a fair criticism attached: incidental findings lead to workups that find nothing and bill for a great deal. He accepts the criticism and keeps the position, with one condition. The radiologist reading it must work in screening rather than diagnosis, or the false positives bury the signal. Cost is about USD 2,500, and it is not covered. Then the blood test. Galleri reads methylation patterns in cell-free DNA and looks across roughly fifty cancer types, including the ones with no screening programme at all: pancreatic, ovarian, liver. Sensitivity in asymptomatic populations is around 51.5 percent overall, lower at stage I and higher later. Specificity is very high, near 99.5 percent, so a false alarm runs about one in two hundred. Around USD 949. A test that finds half of what it looks for, in the places nothing else looks, is not a bad test. It is a bad replacement.

The SELECT trial ran from 2001 to 2011. Thirty-five thousand five hundred and thirty-three men, randomised to vitamin E at 400 international units a day, selenium at 200 micrograms a day, both, or placebo. Vitamin E increased prostate cancer risk, hazard ratio 1.17, an absolute increase of roughly 1.6 cases per 1,000 person-years. The trial stopped early, for futility and for harm. Observational epidemiology had promised the reverse. Vitamin E and selenium were supposed to be protective. That is the whole result: the design with the randomisation, the placebo and the mechanism produced the opposite of what the survey data said. The reasons are not mysterious. Food frequency questionnaires ask a man to recall a year of meals. Healthy user bias means the people who take vitamins also sleep, train and show up for appointments. Relative risks of 1.2 to 1.5 do not survive without a mechanism and a trial. Attia treats supplements as drugs, because they are. Doses, side effects, interactions. High-dose alpha-tocopherol can behave as a pro-oxidant. Selenium above nutritional requirement disturbs insulin signalling. Nobody sells you the hazard ratio. It does not fit on the label.

Tier one, this month: a colonoscopy, a baseline PSA, a full hereditary cancer panel, and an annual full-body skin examination with dermoscopy for anyone with fair skin and a lifetime of UV exposure. Tier two, inside six months: whole-body MRI, and a liquid biopsy added alongside organised screening rather than in place of it. Tier three, ongoing: a metabolic panel that includes an oral glucose tolerance test with insulin, Lp(a), ApoB, a vitamin D level, zone 2 work three or four times a week, VO2 max intervals once or twice, and strength three times. What he would not order: chest imaging in a man who has never smoked, pancreatic surveillance without a high-risk gene, and antioxidants for prevention. I am not handing out a protocol. I am telling you the position I took and the arithmetic under it, because it is the same arithmetic I have used across twelve countries and one Frankfurt listing. The bill arrives either way. The only variable is the date.