The politics of PSA testing

We continue to see a steady stream of articles in the cancer literature that appears to be designed to influence the thinking of the U.S. Preventive Services Task Force (USPSTF) as they reconsider the value of PSA testing in assessment of risk for prostate cancer.

The latest two such articles (which you can read in full for yourself on line) are by Penson and Resnick and by Shoag et al. — both in the Journal of Clinical Oncology. Commentary on these two articles can also be found on the MedPage Today web site.

Intense discussion about the value of PSA testing is an entirely valid and appropriate concept. The “New” Prostate Cancer InfoLink is pleased to see what seems to be a much more realistic presentation of the argument that many, if not all, men should be getting a baseline PSA level in their 40s such that further decisions about future PSA testing can be made with such a clear baseline in place.

Shoag et al. continue to argue that the ERSPC trial “found that PSA screening reduced prostate cancer-specific mortality” without acknowledging that screening is only considered justifiable by epidemiologists if it impacts overall (as opposed to disease-specific) survival. One may have a different perspective on that mindset, but it has been the one epidemiologists have been using for the best part of the past 100 years or so.

Shoag and his colleagues also ignore the fact the the ERSPC investigators themselves have now repeatedly stated that they do not think their results justify mass, population-based screening for risk of prostate cancer.

There is absolutely no doubt that we need to reach a new consensus on the validity of testing for risk of prostate cancer and how this should be conducted and in whom. The place where there does seem to be an increasing level of consensus is that there are high-risk patients whose risk is considerable and for whom, as a consequence, some form of appropriate risk management strategy needs to be put in place. There is less consensus about what to do for the rest of us, and it will be interesting to see whether the USPSTF can find a compromise position that doesn’t just paint things in black and white but really does acknowledge the “shades of grey”.

10 Responses

  1. All-cause mortality with PSA screening will be worse in a cohort of older men compared to a cohort of younger men.

    Which clock will last longer in a man? His prostate clock or his life clock?

  2. When you see men die slowly, very painfully with much suffering and frequently crippled from prostate cancer — as I have done too frequently over the past few years — there seems little justification to ignoring the potential to reduce cancer-specific mortality.

    Maybe these men would die of something else — but the chances are it would not be as drawn out and painful. Every epidemiologist that argues against PSA testing based on no impact on OS should be required to watch a man die of the disease.

  3. Dear Rick:

    As I said, you may not like the definition of benefit from screening, but it doesn’t only apply to prostate cancer. It applies to all forms of illness.

  4. Dear Mark:

    Actually, we have no evidence that that is the case at all.

  5. Rick:

    The point you have made really hit a raw nerve when I first read the USPSTF’s draft recommendation prior to their final recommendation. (It struck the nerve when I saw the final version in 2012 too, but not so sharply as by then I expected a poorly analyzed product, which of course is what we got. I have some hope that the current group will do a better job, based in part on seeing that at least three of the current group deal with oncology, even though none is a urologist or oncologist, as before.)

    I was (and still am) upset that the the USPSTF puts so much emphasis on mortality while almost ignoring some of the other “burden of the disease” such as metastatic disease and also prolonged pain and suffering. I remember seeing my own father sleeping with obvious jolts of pain that the morphine did not completely quell. My mother and brother cared for him during many difficult months when he was nearly totally disabled. I’m convinced some of the voting members of the USPSTF are oblivious to the prolonged pain and suffering endured too often in the final stages of the disease, so unlike a quick death from a heart attack or stroke. Of course that is hard to quantify, while counting a death is far simpler. At the least they could pay more attention to the tally for metastatic cancer, which can be counted easily and is a fairly good proxy for disability, pain, and suffering.

    I addressed this concern in comments on their research plan, and I suspect that many others of us did too. But I saw no sign that their final plan was at all responsive.

  6. Jim:

    There is no point in blaming the USPSTF for the global definition of success in a screening program. This goes back to the earliest days of the development of the idea of screening to limit risk from any disease … when most people were dying very quickly from a whole spectrum of disorders, and the majority of men didn’t live anything like long enough to be of any significant risk of dying from prostate cancer. (Life expectancy for a man in America in 1920 was 53.6 years! Even today, death from prostate cancer at that age is rare in the extreme.)

    If you want to do something about that one, you’ll need to start a whole other type pf movement because it goes way beyond prostate cancer.

  7. Dear Sitemaster:

    I may just try to start that movement. I have some hope that the current USPSTF will get it right this time, but if they blow it again, I believe I will be writing a book to call attention their blunder and call for reform. I already have a title, several planned chapters, and two prominent co-authors in mind. Perhaps you would consider joining in too?

    It strikes me that the USPSTF as currently structured and oriented does not fit well with either current needs or their added influence due to the Affordable Care and Patient Protection Act.

  8. Jim:

    You are missing my point again … The definition of “success” in a screening program has nothing to do with the USPSTF. That is the criterion they are required to apply by the entire global health community. You’ll need to get WHO to change that definition. … And “writing a book” won’t get you beyond the starting gate …

  9. Thanks for your help. It’s one reason I keep coming back.

    WHO is a much larger kettle of fish, but perhaps changing the USPSTF is within reach. After all, even with WHO’s influence, screening practices vary considerably among countries. I see no reason for blinders being used by WHO to be accepted by the US for its USPSTF. After all, another of our health care overseers, the FDA, operates quite independently of similar groups in other countries, as when it prevented the thalidomide disaster in the US.

  10. Dear Jim:

    With the very greatest respect, there is a difference between the policies used by specific countries and global consensus on basic precepts. The USPSTF is not going to change the basic definition of success for a screening program — which is evidence of a statistically significant increase in overall survival.

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