Some readers may want to review the article on the Reuters web site entitled “Health panel takes heat on cancer screening advice.”
In this article, not only do current and past members of the USPSTF appear to acknowledge that they could (and should) do a better job of how they communicate the recommendations that they make. They also give some insight into the political pressures that they are now having to deal with as they try to do their job.
If, as a nation, we don’t wnat to follow the guidance of expert panels, there are mechanisms available to deal with this. However, if we are going to fund expert panels to advise us on what works and what doesn’t, then we need to let them do their jobs without political pressure. Alternatively, we can just eliminate the USPSTF … but if we do that the “New” Prostate Cancer InfoLink is quite sure that some other organization will pick up this particular ball and run with it … and the consequences could be even worse!
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The article on the Reuters web site entitled “Health panel takes heat on cancer screening advice” is worth your time to read.
“and the consequences could be even worse!”
Do you really assume that the consequences of the USPSTF recommendations are “bad”? This seems incongruent with many of your comments throughout the debate on these recommendations to date.
I know that you know that a substantial segment of your audience deeply (and loudly) disagrees with not just the USPSTF’s draft guidelines, but with the capacity of non-urologists to form an opinion on any aspect of prostate cancer screening, diagnosis, treatment, or treatment consequences — and that you want this audience to stay engaged in moving the recommendations forward in ways that will protect high-risk men and stop the gross over-treatment of low-risk men.
As politicized as this issue has become, I would suggest that even casual, general comments can be taken out of context and misconstrued to mean something other than the original speaker intends. I appreciate your modesty, Mike, and the very careful way you present your opinion on both prostate cancer policy issues and in your tireless and constructive correspondence to individuals. But you are also a thought-leader on this issue. As calmly and consistently as you’ve countered the outrage and dissatisfaction of those opposed to the USPSTF’s recommendations, it would be a shame to throw your input away by putting out a contradictory remark intended lightly, but taken — out of context — to be a real and serious criticism. Millions of men at risk of suffering the likely consequences of unnecessary treatment await your clarification.
:)
Tracy:
While I understand how and why the USPSTF came to the conclusions it did, and while I can “live with” its recommendation regarding mass screening for prostate cancer, I have to say that it made a complete hash of how it rolled out its recommendation (yet again), just as it did with the breast cancer recommendation previously. Although both statements are only recommendations, they appear to be absolute fiats because of the way that they are packaged. This failure in communication has led (at least in part) to the political fallout.
Now imagine that there is a further political fallout because one or other political party decides to just stop funding the USPSTF altogether. Who is going to step into the breach? The physician interest groups that already issue recommendations that are in complete contrast to those of the USPSTF? Working groups from the health insurance industry that have a whole other agenda? Public Citizen (which appears to think that all drugs should be completely free of side effects)? I am clear in my mind that the USPSTF does a very good job of analyzing available evidence and making recommendations. By contrast they seem to do an absolutely hopeless job of explaining what their recommendations actually imply — to the primary care community (which they claim as their key audience), to the media (in particular), and to the general public. When I specifically asked a senior member of the task force about the statements in the recommendation that clearly indicate that individual patients and physicians need to interpret this recommendation in light of individualized aspects of care, I was patronizingly praised for having really read through the entire document with considerable care!
Unless the USPSTF can radically revise its communications methods such that it can explain them better, it will remain in massive political danger … and then we most certainly could be faced with “consequences [that] could be even worse.”
Mike
Hi Mike.
Do you agree that the USPSTF failed to understand both prostate cancer and the lack of significance in the results from the PLCO and ERSPC trials published in 2009? Both trials apparently played key roles in their thinking.
While there were several major flaws in both trials, the critical flaw was inadequate duration of follow-up. If median follow-up had been 20 years, or if the disease were a fast-growing cancer such as pancreatic cancer and not prostate cancer, follow-up would have been adequate and other issues (which were also major) would determine the worth of the reports. However, as nearly 100% of men with low- and intermediate-risk prostate cancer are alive at 10 years after diagnosis (at least in the US), and as 95% of men with high-risk disease are alive at that point (again in the US), it should be clear that adequate follow-up is essential to illuminate outcomes of screening for this generally slow-growing but sometimes lethal disease. Unfortunately, both the PLCO and ERSPC trials featured median follow-up from the time of enrollment of healthy men in the screening trials, rather than from the time of diagnosis. As we know, and as documented in the Dutch cohort of the ERSPC trial, several years, at least, will typically elapse from time of initial screening to time of diagnosis. Therefore, the reported median follow-up times of about 10 years or fewer, from dates of enrollment — not diagnosis, really amount to well under 10 years of follow-up from diagnosis. Therefore, while the follow-up periods in these trials are adequate to capture the rare deaths from treatment, which are front-loaded, often occurring during or shortly after surgery, for instance, the reported periods are much too short to capture the benefits, with a few exceptions.
This critical flaw in follow-up is sufficient by itself to invalidate any conclusions about net survival benefit or harm, as I see it. (The NEJM editorial published with the papers also suggested that the reports “may” be premature, which struck me as “polite” language to make a key point.) This flaw alone thoroughly undermines the USPSTF position.
Dear Jim:
No, I do not agree that “the USPSTF failed to understand both prostate cancer and the lack of significance in the results from the PLCO and ERSPC trials published in 2009.” I think they understood these trials well, but they were assessing the available evidence, not the lack of evidence. They interpret the data from these trials differently from you, but that is a different matter.
My problem with the USPSTF has nothing to do with the way they assessed the available evidence (most of which is, frankly, lousy). My problem with the USPSTF is how their (reasonable) conclusion was presented, which is misleading because they are not really saying that individual men shouldn’t get PSA tests. They are saying that there is no good evidence to support mass, population-based, annual screening of otherwise healthy men for prostate cancer with the PSA test. These two apparently contradictory viewponts are not actually incompatible at all.
I also have to tell you that I think that both the PLCO trial and the ERSPC trial were so badly structured that they will never show compelling evidence for a survival benefit, even at 20 years of follow-up. Remember, please, that the ERSCP trial wasn’t really one trial at all … It was a meta-analysis of several different trials with different protocols.
Hi again Mike,
For me, practicalities make screening desirable but problematic at this time. Ideally, I would like to see almost all men screened, but after being educated about several key facts, prominent among them the success of active surveillance for low-risk prostate cancer (with emphasis that it is the most common type these days) in the unlikely event that cancer were to be diagnosed. However, it seems clear that the typical annual or periodic exam is done by a general practitioner who may well not have the time, expertise, or motivation to educate the patient. While written or visual material could fill that communication gap, with follow-up questions for a doctor who has been trained in screening education for prostate cancer, I’m not aware that that is happening.
The present reality appears to be that many men being screened are still hustled to urologists for biopsies, and then 90% of newly diagnosed patients do not choose active surveillance even when they are eligible for it, thereby generating the over-treatment problem. Of course we survivors and advocates can do our bit by explaining what’s up, but it would help if major insurers would take the lead, offering incentives for men (and their spouses) to educate themselves about screening. My insurer is already using such an approach for other health concerns.
This is a long way of saying I’m in favor of screening but am also not so fond of uninformed mass screening.
About the USPSTF’s understanding of the PLCO and ERSPC trials
(responding to part of 12/21/2011 response)
When you read the draft guidance on screening, you come across nearly opposed appraisals of the trials. In some instances – unfortunately the key instances – the trials seemed to me to be taken at face value and their findings and conclusions accepted. In other instances, the draft notes serious deficiencies in the trials. My take-away impression was that the USPSTF as a whole did not come to grips with the impact of the flaws on the conclusions in each paper, instead, in effect, ignoring the flaws. It was as if the USPSTF was a committee that did not resolve key issues but did allow a minority view to be expressed, which happens in other venues, such as ODAC committee hearings (ODAC at least having the excuse of tight timeframes).
Perhaps the Task Force will do another draft that comes closer to your version of their conclusion.
Jim:
There won’t be “another draft” … only a final report … although quite when is less clear.