Monday, June 22, 2015

USPTF and its Consequences

Over the past few years as a direct result of the ACA we have seen positions taken by the USPTF on prostate and breast cancer. Women revolted and the USPTF was overturned. Men have just died.

Now in a recent article there are the quantitative results, assuming anyone can believe the Government records, remember the PSA data problem. In the Journal of Urology the author's state:

There was a 28% decline in incident diagnoses of prostate cancer in the year following the USPSTF draft recommendation against PSA screening. This study helps quantify the potential benefits (reduced harms of overdiagnosis and overtreatment of low risk disease and disease found in elderly men) and potential harms (missed opportunities to diagnose important cancers in men who may benefit from treatment) of this guideline.

The cause seems to be the following of the USPTF guidelines. Namely fewer diagnoses have been made because fewer tests have been performed but if we waith another few years we will see greater mortality.

Just to recall several facts:

1. The US and European studies in NEJM a while back were in our opinion flawed. The US study just looked at a PSA of 4 and did not account for velocity, percent free, age, size, and family history. The European study not only was faulty for those reasons but it samples once every 2-3 years, much too long a period for aggressive PCa.

2. PSA is useful if and in our analysis and opion only if its is done and recorded over time, accounts for the size of the prostate, measures velocity, and accounts for percent free PSA. Unfortunately despite all the pressure on EHRs the temporal statistics on patients is ignored.

Thus we see the results starting to appear. In Science Daily the writes notes:

The study identified a drop of 28.1 percent in diagnoses of intermediate-risk disease and 23.1 percent in high-risk prostate cancer one year after the draft guideline. The decline did not vary across age or comorbidity features. 'These findings suggest that reduced screening may result in missed opportunities to spare these men from progressive disease and cancer death,' said Barocas. While the observation period was too limited to determine the impact on the diagnosis of metastatic prostate cancer, which is associated with a high treatment burden, decrease in quality of life and increased mortality, the authors did observe a small upward trend in diagnoses of non-localized disease. 'The results raise concern that if this trend continues more men may be diagnosed at a point when their disease is advanced. Younger, healthier men with intermediate or high-risk disease would normally be candidates for aggressive local therapy and they may not be receiving a timely diagnosis under this policy,' said Barocas. The authors suggest that future research should focus on screening regimens that minimize harms and maximize potential benefits of screening, while also considering patient preferences.

It will be essential to continue to monitor this result but at the same time use what tools we have clinically to deal with those at higher risk, for example those with strong family histories. The USPTF in my opinion may very well have caused the demise of thousands in the long run.