The USPSTF is at it Again

The USPSTF had previously made a recommendation that PSA testing did not have any positive effect in mortality. So frankly they said "stop it". Then various studies indicated they were wrong. The two NEJM studies in 2009 that the USPSTF relied upon were fatally flawed for a variety of reasons, many of which we discussed here at the time (See recent NEJM comments ).

The folks at the USPSTF are now back at it again. This time to try and put a stake through the hear of PSAs. It seems they just want to get rid of old men. That's one way to cut Medicare.

The USPSTF has proposed a study whose goals are:

1. Is there direct evidence that prostate cancer-specific antigen (PSA)-based screening for prostate cancer reduces short- or long-term prostate cancer morbidity and mortality and all-cause mortality?
   1. Does the effectiveness of PSA-based screening vary by subpopulation/risk factor (e.g., age, race/ethnicity, family history, and clinical risk assessment)?
2. What are the harms of PSA-based screening for prostate cancer and diagnostic followup?
   1. Do the harms of PSA-based screening for prostate cancer and diagnostic followup vary by subpopulation/risk factor (e.g., age, race/ethnicity, family history, and clinical risk assessment)?
    

Frankly they already seem biased. But that is not just my view. As Medscape notes:

"Finding high-quality data to answer this will be challenging," Dr Hoffman told Medscape Medical News. None of the major screening trials enrolled men younger than 50 years, most subjects were white, and investigators did not routinely assess clinical risk. "While some studies are now recruiting patients to address screening in higher-risk populations, it will likely take at least a decade to determine the effects of screening on morbidity and mortality," he summarized. In the meantime, Dr Hoffman is concerned that "abandoning PSA screening" is proving harmful. The rate of distant-stage prostate cancers in the United States is increasing, according to a population-based study for which he was lead author. However, "it's too early to tell whether this will lead to an increase in prostate cancer mortality," he said. The USPSTF research plan separates the review of evidence about the potential harms of PSA testing, biopsy, and treatment.

Indeed to validate these questions takes time, and a decade is not bad. The issues of "harms" is so individual and personal it appears that only the Government can make the decision for all of us. Why not, but perhaps they did not notice the recent elections!

I have noted the complexity of the PSA test. It is far from perfect. The Bayesian analysis is also far from perfect. Namely increasing PSA, or PSA velocity is not a clear indicator, family history is not a clear indicator, a prior biopsy with HGPIN is not a clear indicator, and a contrast MRI using diffusion weighting is not a clear indicator! So what is? Ultimately it is a biopsy, but even that samples some 1-2% of the tissue.

So what is the solution. For those who recall the Hippocratic Oath, "Do no Harm!"