The USPSTF Finally Acts on Prostate Cancer Screening Test

October 7, 2011
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Two-and-a-half years after studies appeared in the New England Journal of Medicine questioning the efficacy of routine prostate cancer screening for middle-aged men, the U.S. Preventive Services Task Force finally issued its recommendation based on a review of the science. Its recommendation: don’t bother taking the test.

I have no idea if their action was precipitated by recent scientific revelations that nearly half the men who undergo treatments for cancers suffer serious side effects like impotence and incontinence (see this GoozNews post), or the appearance this weekend of a major New York Times magazine article by Shannon Brownlee and Jeanne Lenzer airing the controversies around the test. But there’s no doubt that politics and fear of a right-wing backlash delayed this recommendation. Here’s the Brownlee/Lenzer summary of that controversy:

According to an internal document, in 2009 the task force conducted an in-depth analysis of data and seemed poised to give routine P.S.A. testing a “D” rating — “D” as in don’t do it — for any man of any age. But this was around the time that the task force stated that routine mammography for women ages 40 to 50 was not necessary for every woman. That recommendation caused a public uproar, and Ned Calonge, the task-force chairman at the time, sent the P.S.A. recommendation back for review. One year later, in November 2010, just before midterm elections, the task force was again set to review its recommendation when Calonge canceled the meeting. He says that word leaked out that if the November meeting was held, it could jeopardize the task force’s financing. Kenneth Lin, the researcher who led the review, quit his job in protest, and now, nearly two years after its initial finding, it remains uncertain when the task force will release its rating for P.S.A. screening.

Well, better late than never. I salute the USPSTF’s willingness to finally take on this controversy. It’s now imperative that all journalists who believe in the primacy of science over the politics of self-interest carefully scrutinize those who will no doubt question this decision in the days ahead. It should begin by fully vetting whether they earn their living by offering surgery and radiation to people diagnosed with early stage prostate cancer; whether they have invested in or would benefit from patents and royalties associated with any aspect of treatment; and where, if they are with an advocacy group, their funding comes from.

Here’s my own blog post from March 2009, when the NEJM studies first appeared. It’s last sentence called for the actions taken yesterday by the USPSTF:

I recently received word that an old friend, someone I hadn’t seen since 1991, passed away at age 90. Arnie and I became friends in the late 1980s because my significant other (soon-to-be wife) and his new significant other, a woman who was about 20 years his junior, were close friends. Around 1989, Arnie told us over dinner that he had prostate cancer — a diagnosis produced by a PSA or prostate specific antigen test followed by a biopsy.

Arnie, a bushy-eyebrowed teddy bear of a man, was an old-school psychiatrist. He believed in Eros, Thanatos and talk therapy. Prozac nation wasn’t for him, and in his semi-retirement he continued to see the few patients whose insurance would either pay for regular visits or could afford the sessions on their own.

At the time, knowing nothing about medicine, I was bit skeptical about his response to a cancer diagnosis. But over dinner, the last and only time we ever spoke about the disease, he explained his choice of foreging treatment. There was no way he was going to risk becoming impotent. Better to die, he said, smiling gently at his 50-year-old (soon to be a grandmother) girlfriend. When she emailed the sad news of his passing, my wife didn’t even think to ask from what.

Contrast Arnie’s decision with that of my father, who was diagnosed with prostate cancer a few years later. In his early 70s, he was already in a noticeable downhill slide from dementia. On the advice of his doctors, whose word he and my mother would never even begin to think to question, dad had a radical prostatectomy. And over the last four years of his life, which was mercifully ended by pneumonia after most of his cognitive brain function had been destroyed, my late mother had to care not just for a demented old man, but an incontinent one.

These two very different responses to a prostate cancer diagnosis in late middle or early old age highlight the horrible dilemma thousands of men experience every year due to widespread PSA testing. The two studies published in the New England Journal of Medicine today (see here and here) provide more evidence that for most men, PSA testing as currently practiced is unnecessary and a waste of health care system resources.

The National Cancer Institute-funded study found that screening identified 17 percent more cancers after ten years, but didn’t significantly reduce the number of deaths. A European study found that screening could marginally reduce the prostate cancer death rate, but that 1,410 men would need to be screened for ten years and 48 would have to be treated for prostate cancer to prevent one death. In other words, 48 men would have to experience the debilitating side effects of prostate cancer treatment in order to extend the life of one older man who may soon die of some other disease.

There was widespread coverage of these studies in today’s news and it struck the right note, which isn’t surprising given that even the head of the American Cancer Society now questions the usefulness of widespread prostate cancer screening tests. Otis Brawley told the Washington Post:

I know guys who are morbidly depressed because of the complications of their prostate cancer treatment. I know three people who attempted suicide. I know widows of guys who died from their treatment. There are significant harms associated with over-treatment of prostate cancer.

The U.S. Preventive Services Task Force recently recommended that men over 75 no longer receive prostate cancer screening tests. It said the evidence for younger men was equivocal and took no position.

Yes, these latest trials were rushed into print, and the prostate cancer screening lobby (see the website of the partially industry-funded Prostate Conditions Education Council to get a flavor for its boosterism) was quick to suggest longer-term follow-up may turn up a larger health benefit. But the disturbing data contained in these studies, which corroborate the experiences of thousands of families who have been needlessly subjected to biopsies and treatment when watchful waiting was more appropriate, suggest the USPSTF ought to reconvene its committee and rethink its recommendations for younger men.

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3 Responses to The USPSTF Finally Acts on Prostate Cancer Screening Test

  1. John from Tucson on October 8, 2011 at 3:26 pm

    I notice that your bio indicates you have financial reporting background. When you are a hammer everything may look like a nail – so PSA testing or any diagnostic or drug might appear to be financially motivated to you.

    My background is 30 years at FDA – yasss inside the beltway – and I am here to tell you that it is not “right wing” to question the credentials of entities like USPSTF. Let’s face it – Sen Mikulski had to bsil them out with her amendment re: mammography testing. The fact is, if you read the amended section, the only change to the USPSTF authority is to vacate decisions reached in Nov 2009 – i.e. the “Class C” rating for mammograms for women between 40 and 50 – though the actual procedure is never specifically mentioned – not surprising for a bureaucratic entity that supposedly never makes mistakes and needs to cover tracks.

    Such a lack of corrective action, especially in view of the abject failure of their methodology, is appalling. Why aren’t there specific requirements for pathology-specific expertise on the panel? Why aren’t there requirements for benchmarking to current standards and outreach to other groups of experts? Why isn’t there a periodic monitoring function to evaluate impact of new decisions? Why isn’t there some appeals process for affected demographics? Does each demographic group damaged by some new USPSTF decision need to get “political” and find their own Sen. Mikulski? Where is the fairness for those in small demographics with “unpopular” conditions?

    In my work at FDA I became familiar with several health care debacles that could be laid directly at the feet of initiatives and funding decisions at the Federal level. These never became Public, except that the NY Times did guess at a couple. Regarding the current USPSTF decision on PSA testing, I have no way of knowing – they could be right … but on the other hand, in view of their past failure, and in view of the absolute lack of checks on this group they could very well be wrong.

    What makes this so problematic is their empowerment by the new Health Care Act (Sec 2713). This empowerment makes what might, in the past, have amounted to just bad advice that physicians and insurers could work around, deadly serious business that cannot be ignored.

    I would guess that the delay in the USPSTF ruling comes at least in part because of the lack of confidence this group has in the validity of their methodology, the potential impact a decision now has, and the vulnerability of their rulings to censure by other experts (the great motivator within the bureaucratic community). I believe USPSTF is probably way out of their depth – as are you.

    Regards
    John

  2. Francine Hardaway on October 10, 2011 at 5:35 am

    And then there ‘s Gerry Kaplan, who tried to ignore the diagnosis until the kids and I forced him to reconsider, and then died in four years because he was treated too late and the cancer was already in a node. One small node.
    in principle, you are right.

  3. Ben Rush MD on October 12, 2011 at 9:43 am

    Statistics are like Bikinis – What they reveal is suggestive but what they conceal is vital.

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