Opinions on the USPSTF recommendation are all over the map — and all “off the money”

As one might expect, there is an extremely diverse (and conflicting) range of reactions to the USPSTF recommendation that routine PSA testing of uninformed men is not supported by good evidence and should no longer be considered as appropriate “standard” practice unless there has been a prior discussion of the risks and benefits of the test between patient and doctor. We’ll explain what we mean by “off the money” at the end of this piece.

The American Urological Association (AUA) and a number of prostate cancer-related organizations have reacted with “shock and horror” to this recommendation, as indicated by the following public statements and initiatives:

There was an excellent discussion of the topic on The Diane Rehm Show on WAMU in Washington, DC, earlier this week, and the complete transcript is available on line. It is clear from that program that this is far from being a simple issue. Another public radio program (yesterday) was based on discussions with two African-American physicians.

In an OpEd in The Washington Post on Tuesday this week, Michael Milken — the Chairman of the Prostate Cancer Foundation — published comments (“Why block a cancer test that saves lives?“) which, if taken at face value, could seem to conflict with the media release issued by the organization itself on the same day.

But then there are some very different points of view, reflected in recent articles such as the following, that reflect how PSA testing has led to severe, life-threrateing illnesses and even deaths in previously healthy patients:

Naturally, our political class is also weighing in with opinions that are probably more about winning votes than they are about sound, evidence-based knowledge.

Sadly, the American Cancer Society has issued no statement at all. They have simply re-posted a blog commentary by Otis Brawley, MD, originally published in June this year.

So what do we mean by “off the money”?

There is a real bottom line to all of this that has to do with whether Medicare, Medicaid, and the world of commercial insurance will continue to cover the costs of PSA testing for “healthy” men if the USPSTF recommendation is formalized after the comment period (which The “New” Prostate Cancer InfoLink believes it will).

At least in theory, this recommendation could be used to justify the decision that Medicare and commercial insurers should not continue to pay for “screening” tests for prostate cancer in such healthy males. The conspiracy theorists are already arguing that the recommendation was a “set up” to allow the government to cut “billions of dollars” spent on screening for prostate cancer.

So … let us be very clear …

The “New” Prostate Cancer InfoLink believes that the USPSTF recommendation is actually accurate and helpful. We believe that men need to understand the risks and benefits of a PSA test before they have one. We also believe that, at this time, the PSA test is the only test available that can help a healthy man to have expanded understanding of his personal risk for clinically significant prostate cancer. (We are all at high risk for having some prostate cancer cells in our prostates as we age … but that isn’t the same thing as clinically significant disease.)

Given these realities, failure to cover the costs of thoughtful use of the PSA test in men who have been informed about the risks and benefits of this test would be unethical and inappropriate. We need a better test for risk of prostate cancer. Of that there is no doubt. However, we need to categorically separate the recommendation of the USPSTF about the use of the PSA test today from any issue related to coverage of the costs involved in its appropriate use. We do need to use the PSA test with greater care … but as a society we absolutely need to cover the costs involved in that use.

6 Responses

  1. I find it frightening that an advocacy group would think that a collection of anecdotes should sway the panel over the results of controlled clinical trials. Most of the advocacy groups are doing far more harm than good for the group they are representing with their vilification of the USPSTF.

    I find it even more frightening that urologists are continuing promote “business as usual” for screening, with many publicly misrepresenting both the statements of the USPSTF and the benefits of screening. I previously thought it was professional negligence to allow the proliferation of PSA screening to uninformed (or misinformed) men. To continue to promote it borders on criminal recklessness. (Despite the title, the AUA official statement doesn’t even mention discussion with a doctor until deciding on treatment of a cancer that has already been diagnosed.) I am disgusted by the overall reaction to the USPSTF statement and sickened by the blatant hypocrisy of the AUA.

    I admire and thank the sitemaster (Mike, I believe your name is from long-term lurking) for your tireless efforts in providing a rational, rather than emotional, representation of the issues involved. You are doing a great deal of good here.

  2. Jim:

    Let’s just say that there are a number of advocacy groups and the range of viewpoints is considerable. I do understand why many people react to things like the USPSTF recommendation with such fury, but I also think it is high time that the USPSTF was recognized for what it is and not simply painted as a set of government bureaucrats trying to constrain people’s rights to whatever they think they should get regardless of good or poor scientific evidence.

  3. Visitors to this site who might want to read more about how misleading claims that PSA screening “saves lives” are made, they might like to read the article that Shannon Brownlee and I wrote in the New York Times Magazine.

  4. Loved the article (and the graphic!) by Jeanne Lenzer and Shannon Brownlee referenced above. I also found the characterizations used by Mr. West entertaining. I’ve put my reactions in a post on another site.

    Prostate problems are a binary circumstance: you either have them or you don’t. In many instances, they are asymptomatic, so (if you are curious) you must proactively seek out a diagnostic test to find out if you are in “Group A” or “Group B.” Once you get the news that you are in “Group B,” you can engage in further intrusive testing or pass on the whole idea.

    Note the various decision points: Do I want to find out which group I am in? If I am in the “abnormal” group, do I want to find out the characteristics of the abnormality? Once I find out the characteristics, do I want to engage in treatment? Once I decide on active treatment, which protocol do I follow?

    We make these decisions as an individual in collaboration with family and physicians. I emphasize that these are personal decisions. We as individuals are the ones who roll the dice and suffer the consequences. We try to make informed decisions within the constructs and limitations of the medical community, but that is all we can do. We are in “Group B” and try to work the best we can with the hand we are dealt.

    Pardon the metaphors, but the point to keep in mind is that while men have a whole continuum of prostate health issues, the USPSTF chooses to focus on one limited aspect. Doesn’t the idea that a minimally invasive blood test must be censured seem a bit Orwellian?

  5. Dear Howard:

    I find it interesting that while you see what the USPSTF is suggesting as “censuring”, there are others who see it as seeking to ensure that, as you take the first step in what is clearly a dubious journey, you are shown a sign that says, “Travel on this pathway is potentially dangerous and subject to unexpected risk. Please take appropriate precautions.”

    No one is telling you not to go down this pathway. USPSTF is simply suggesting you receive a clear caution, as opposed to letting you get half way down the path before you realize that you can’t turn back!

    (Nothing like a good metaphor to make a point!)

  6. Sitemaster:

    Thanks for the follow-up. I think we are going to have to “agree to disagree” on this one. A “D” rating by the USPSTF is not so much “a sign” as a fully functioning roadblock. I believe the healthcare industry will see it as a mandate, rather than an advisory or suggestion, but we will just have to stay tuned. …

    Thanks for hosting the forum!

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